Summary of Benefits and Coverage Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning on or after 01/01/2018 : Silver70 HMO 1000/50 Alt Coverage for: Family | Plan Type: Deductible HMO Line only for company identifying information [NW underwriting, MAS address] The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see www.kp.org/plandocuments or call 1-800-278-3296 (TTY: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at http://www.healthcare.gov/sbc-glossary or call 1-800-278-3296 (TTY: 711) to request a copy. Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount What is the overall before this plan begins to pay. If you have other family members on the plan, each $1,000 Individual / $2,000 Family deductible? family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the deductible Are there services amount. But a copayment or coinsurance may apply. For example, this plan covers Yes. Preventive care and services indicated in covered before you meet certain preventive services without cost-sharing and before you meet your chart starting on page 2 your deductible? deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other Yes. $250 Individual / $500 Family for brand and You must pay all of the costs for these services up to the specific deductible amount deductibles for specific specialty prescription drugs. There are no other before this plan begins to pay for these services. services? specific deductibles. The out-of-pocket limit is the most you could pay in a year for covered services. If What is the out-of-pocket $7,000 Individual / $14,000 you have other family members in this plan, they have to meet their own out-of- limit for this plan? Family pocket limits until the overall family out-of-pocket limit has been met. What is not included in Premiums, and health care services this plan Even though you pay these expenses, they don’t count toward the out–of–pocket the out-of-pocket limit? doesn’t cover, indicated in chart starting on page 2. limit. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you Will you pay less if you Yes. See www.kp.org or call 1-800-278-3296 might receive a bill from a provider for the difference between the provider’s charge use a network provider? (TTY: 711) for a list of network providers. and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to This plan will pay some or all of the costs to see a specialist for covered services but Yes, but you may self-refer to certain specialists. see a specialist? only if you have a referral before you see the specialist.

Plan ID: 10381/10382_CC_2018_v2 1 of 6

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay Common Limitations, Exceptions, & Other Important Services You May Need Plan Provider Non-Plan Provider Medical Event Information (You will pay the least) (You will pay the most) Primary care visit to treat $50 / visit, deductible does not Not covered None an injury or illness apply If you visit a health $70 / visit, deductible does not Specialist visit Not covered None care provider’s apply office or clinic Preventive You may have to pay for services that aren’t No charge, deductible does not care/screening/ Not covered preventive. Ask your provider if the services needed apply immunization are preventive. Then check what your plan will pay for. X-ray: $65 / encounter, deductible Diagnostic test (x-ray, does not apply; Lab tests: $50 / Not covered None blood work) encounter, deductible does not If you have a test apply. Imaging (CT/PET scans, $350 / procedure Not covered None MRIs) Plan pharmacy: $25 retail, Up to 30-day supply retail and 100-day supply mail If you need drugs Generic drugs Not covered $50 mail order / prescription, order. Subject to formulary guidelines. to treat your illness deductible does not apply or condition Plan pharmacy: $70 retail, More information Up to 30-day supply retail and 100-day supply mail Preferred brand drugs Not covered about prescription $140 mail order / prescription, order. Subject to formulary guidelines. drug coverage is after drug deductible. Non-preferred brand Same as preferred brand drugs when approved available Same as preferred brand drugs Not covered at drugs through exception process. 20% coinsurance up to $250 / www.kp.org/formulary Specialty drugs Not covered Up to 30-day supply. Subject to formulary guidelines. prescription, after drug deductible. Facility fee (e.g., ambulatory surgery 35% coinsurance Not covered None center) If you have outpatient surgery Physician/surgeon fees 35% coinsurance Not covered None

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What You Will Pay Common Limitations, Exceptions, & Other Important Services You May Need Plan Provider Non-Plan Provider Medical Event Information (You will pay the least) (You will pay the most) Coinsurance, is waived if admitted to hospital as Emergency room care 35% coinsurance 35% coinsurance inpatient. If you need Emergency medical immediate medical 35% coinsurance 35% coinsurance None transportation attention $50 / visit, deductible does not $50 / visit, deductible Non-Plan providers covered when temporarily outside Urgent care apply. does not apply. the service area. Facility fee (e.g., hospital 35% coinsurance Not covered None If you have a room) hospital stay Physician/surgeon fees 35% coinsurance Not covered None $50 / individual visit. deductible Mental / Behavioral health: $25 / group visit, If you need mental does not apply. deductible does not apply. Outpatient services Not covered health, behavioral No charge for other outpatient Substance Abuse: $5 / group visit, deductible does health, or substance services. not apply. abuse services Inpatient services 35% coinsurance Not covered None Depending on the type of services, a copayment, No Charge, deductible does not coinsurance, or deductible may apply. Maternity care Office visits Not covered apply. may include tests and services described elsewhere in the SBC (i.e. ultrasound.) If you are pregnant Childbirth/delivery 35% coinsurance Not covered None professional services Childbirth/delivery facility 35% coinsurance Not covered None services No Charge, deductible does not Up to 2 hour limit / visit, up to 3 visits limit / day, up to Home health care Not covered apply. 100 visit limit / year Inpatient: 35% coinsurance; If you need help Rehabilitation services Outpatient: $65 / visit, deductible Not covered None recovering or have does not apply. other special health Inpatient: 35% coinsurance; needs Habilitation services Outpatient: $65 / visit, deductible Not covered None does not apply. Skilled nursing care 35% coinsurance Not covered Up to 100 days limit / benefit period.

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What You Will Pay Common Limitations, Exceptions, & Other Important Services You May Need Plan Provider Non-Plan Provider Medical Event Information (You will pay the least) (You will pay the most) Durable medical 35% coinsurance, deductible Not covered Subject to formulary guidelines. equipment does not apply No charge, deductible does not Hospice services Not covered None apply No charge, deductible does not Children’s eye exam Not covered None apply If your child needs No charge, deductible does not Does not apply to out-of-pocket limit. Limited to one Children’s glasses Not covered dental or eye care apply pair of glasses / year from select frames and lenses. Children’s dental check- You may have other dental coverage not described Not covered Not covered up here.

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)  Cosmetic surgery  Infertility treatment  Private-duty nursing  Dental care (Adult)  Long-term care  Routine foot care unless medically necessary  Hearing aids  Non-emergency care when traveling outside the U.S  Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Abortion  Bariatric surgery  Routine eye care (Adult)  Acupuncture (20 visits limit/year combined  Chiropractic care (20 visits limit/year combined with with chiropractic) acupuncture)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,

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contact the agencies in the chart below. Additionally, a consumer assistance program can help you file your appeal. Contact the California Department of Managed Health Care and Department of Insurance at 980 9th St, Suite #500 Sacramento, CA 95814, 1-888-466-2219 or http://www.HealthHelp.ca.gov.

Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights: Kaiser Permanente Member Services 1-800-278-3296 (TTY: 711) or www.kp.org/memberservices Department of Labor’s Employee Benefits Security Administration 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform Department of Health & Human Services, Center for Consumer Information & Insurance Oversight 1-877-267-2323 x61565 or www.cciio.cms.gov California Department of Insurance 1-800-927-HELP (4357) or www.insurance.ca.gov California Department of Managed Healthcare 1-888-466-2219 or www.healthhelp.ca.gov/

Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-788-0616 (TTY: 711) Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-278-3296 (TTY: 711) Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-757-7585 (TTY: 711) Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-278-3296 (TTY: 711) ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

5 of 6 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans . Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow hospital delivery) controlled condition) up care)  The plan’s overall deductible $1,000  The plan’s overall deductible $1,000  The plan’s overall deductible $1,000  Specialist copayment $70  Specialist copayment $70  Specialist copayment $70  Hospital (facility) coinsurance 35%  Hospital (facility) coinsurance 35%  Hospital (facility) coinsurance 35%  Other (blood work) copayment $50  Other (blood work) copayment $50  Other (x-ray) copayment $65

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical Childbirth/Delivery Professional Services disease education) supplies) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray) Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $1,000 Deductibles* $300 Deductibles $700 Copayments $700 Copayments $2,800 Copayments $500 Coinsurance $2,900 Coinsurance $400 Coinsurance $200 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $60 Limits or exclusions $50 Limits or exclusions $0 The total Peg would pay is $4,660 The total Joe would pay is $3,550 The total Mia would pay is $1,400

Plan ID: 10381/10382_CC_2018_v2 6 of 6 The plan would be responsible for the other costs of these EXAMPLE covered services.

Covered California for Small Business Plan Combined Membership Agreement, Disclosure Form, and Evidence of Coverage

Kaiser Foundation Health Plan, Inc. Northern and Southern California Regions

A nonprofit corporation

EOC #74 - Kaiser Permanente Deductible HMO Plan Combined Disclosure Form and Evidence of Coverage for COVERED CALIFORNIA FOR SMALL BUSINESS

Kaiser Permanente Silver 70 HMO 1000/50 Alt Group ID: 799999 Group ID: 399999 Group ID: 799997 Group ID: 399997

Contract Year 2018

Member Service Contact Center 24 hours a day, seven days a week (except closed holidays) 1-800-464-4000 (TTY users call 711) kp.org

Language Assistance Services English: Language assistance is available at no cost to you, 24 hours a day, 7 days a week. You can request interpreter services, materials translated into your language, or in alternative formats. Just call us at 1-800-464-4000, 24 hours a day, 7 days a week (closed holidays). TTY users call 711.

Hmong: Muajkwc pab txhais lus pub dawb rau koj, 24 teev ib hnub twg, 7 hnub ib lim tiam twg..Koj thov tau cov kev pab txhais lus, muab cov ntaub ntawv txhais ua koj hom lus, los yog ua lwm hom.Tsuas hu rau 1-800-464-4000, 24 teev ib hnub twg, 7 hnub ib lim tiam twg (cov hnub caiv kaw). Cov neeg siv TTY hu 711.

Russian: Мы бесплатно обеспечиваем Вас услугами перевода 24 часа в сутки, 7 дней в неделю. Вы можете воспользоваться помощью устного переводчика, запросить перевод материалов на свой язык или запросить их в одном из альтернативных форматов. Просто позвоните нам по телефону 1-800-464-4000, который доступен 24 часа в сутки, 7 дней в неделю (кроме праздничных дней). Пользователи линии TTY могут звонить по номеру 711.

Spanish: Contamos con asistencia de idiomas sin costo alguno para usted 24 horas al día, 7 días a la semana. Puede solicitar los servicios de un intérprete, que los materiales se traduzcan a su idioma o en formatos alternativos. Solo llame al 1-800-788-0616, 24 horas al día, 7 días a la semana (cerrado los días festivos). Los usuarios de TTY, deben llamar al 711.

Tagalog: May magagamit na tulong sa wika nang wala kang babayaran, 24 na oras bawat araw, 7 araw bawat linggo. Maaari kang humingi ng mga serbisyo ng tagasalin sa wika, mga babasahin na isinalin sa iyong wika o sa mga alternatibong format. Tawagan lamang kami sa 1-800-464-4000, 24 na oras bawat araw, 7 araw bawat linggo (sarado sa mga pista opisyal). Ang mga gumagamit ng TTY ay maaaring tumawag sa 711.

Vietnamese: Dịch vụ thông dịch được cung cấp miễn phí cho quý vị 24 giờ mỗi ngày, 7 ngày trong tuần. Quý vị có thể yêu cầu dịch vụ thông dịch, tài liệu phiên dịch ra ngôn ngữ của quý vị hoặc tài liệu bằng nhiều hình thức khác. Quý vị chỉ cần gọi cho chúng tôi tại số 1-800-464-4000, 24 giờ mỗi ngày, 7 ngày trong tuần (trừ các ngày lễ). Người dùng TTY xin gọi 711.

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Kaiser Permanente does not discriminate on the basis of age, race, ethnicity, color, national origin, cultural background, ancestry, religion, sex, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, source of payment, genetic information, citizenship, primary language, or immigration status.

Language assistance services are available from our Member Services Contact Center 24 hours a day, seven days a week (except closed holidays). Interpreter services, including sign language, are available at no cost to you during all hours of operation. We can also provide you, your family, and friends with any special assistance needed to access our facilities and services. In addition, you may request health plan materials translated in your language, and may also request these materials in large text or in other formats to accommodate your needs. For more information, call 1-800-464-4000 (TTY users call 711).

A grievance is any expression of dissatisfaction expressed by you or your authorized representative through the grievance process. A grievance includes a complaint or an appeal. For example, if you believe that we have discriminated against you, you can file a grievance. Please refer to your Evidence of Coverage or Certificate of Insurance, or speak with a Member Services representative for the dispute resolution options that apply to you. This is especially important if you are a Medicare, Medi-Cal, MRMIP, Medi-Cal Access, FEHBP, or CalPERS member because you have different dispute resolution options available.

You may submit a grievance in the following ways: • By completing a Complaint or Benefit Claim/Request form at a Member Services office located at a Plan Facility (please refer to Your Guidebook for addresses) • By mailing your written grievance to a Member Services office at a Plan Facility (please refer to Your Guidebook for addresses) • By calling our Member Service Contact Center toll free at 1-800-464-4000 (TTY users call 711) • By completing the grievance form on our website at kp.org

Please call our Member Service Contact Center if you need help submitting a grievance.

The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to discrimination on the basis of race, color, national origin, sex, age, or disability. You may also contact the Kaiser Permanente Civil Rights Coordinator directly at One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

Kaiser Permanente no discrimina a ninguna persona por su edad, raza, etnia, color, país de origen, antecedentes culturales, ascendencia, religión, sexo, identidad de género, expresión de género, orientación sexual, estado civil, discapacidad física o mental, fuente de pago, información genética, ciudadanía, lengua materna o estado migratorio.

La Central de Llamadas de Servicio a los Miembros (Member Service Contact Center) brinda servicios de asistencia con el idioma las 24 horas del día, los siete días de la semana (excepto los días festivos). Se ofrecen servicios de interpretación sin costo alguno para usted durante el horario de atención, incluido el lenguaje de señas. También podemos ofrecerle a usted, a sus familiares y amigos cualquier ayuda especial que necesiten para acceder a nuestros centros de atención y servicios. Además, puede solicitar los materiales del plan de salud traducidos a su idioma, y también los puede solicitar con letra grande o en otros formatos que se adapten a sus necesidades. Para obtener más información, llame al 1-800-788-0616 (los usuarios de la línea TTY deben llamar al 711).

Una queja es una expresión de inconformidad que manifiesta usted o su representante autorizado a través del proceso de quejas. Una queja incluye una queja formal o una apelación. Por ejemplo, si usted cree que ha sufrido discriminación de nuestra parte, puede presentar una queja. Consulte su Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro (Certificate of Insurance), o comuníquese con un representante de Servicio a los Miembros (Member Services) para conocer las opciones de resolución de disputas que le corresponden. Esto tiene especial importancia si es miembro de Medicare, Medi-Cal, MRMIP (Major Risk Medical Insurance Program, Programa de Seguro Médico para Riesgos Mayores), Medi-Cal Access, FEHBP (Federal Employees Health Benefits Program, Programa de Beneficios Médicos para los Empleados Federales) o CalPERS ya que dispone de otras opciones para resolver disputas.

Puede presentar una queja de las siguientes maneras: • completando un formulario de queja o de reclamación/solicitud de beneficios en una oficina de Servicio a los Miembros ubicada en un centro del plan (consulte las direcciones en Su Guía) • enviando por correo su queja por escrito a una oficina de Servicio a los Miembros en un centro del plan (consulte las direcciones en Su Guía) • llamando a la línea telefónica gratuita de la Central de Llamadas de Servicio a los Miembros al 1-800-788-0616 (los usuarios de la línea TTY deben llamar al 711) • completando el formulario de queja en nuestro sitio web en kp.org

Llame a nuestra Central de Llamadas de Servicio a los Miembros si necesita ayuda para presentar una queja.

Se le informará al coordinador de derechos civiles (Civil Rights Coordinator) de Kaiser Permanente de todas las quejas relacionadas con la discriminación por motivos de raza, color, país de origen, género, edad o discapacidad. También puede comunicarse directamente con el coordinador de derechos civiles de Kaiser Permanente en One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612.

También puede presentar una queja formal de derechos civiles de forma electrónica ante la Oficina de Derechos Civiles (Office for Civil Rights) en el Departamento de Salud y Servicios Humanos de los Estados Unidos (U. S. Department of Health and Human Services) mediante el portal de quejas formales de la Oficina de Derechos Civiles (Office for Civil Rights), en ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo postal o por teléfono a: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697(línea TDD). Los formularios de queja formal están disponibles en www.hhs.gov/ocr/office/file/index.html.

TABLE OF CONTENTS

Health Plan Benefits and Coverage Matrix ...... 1 Introduction ...... 3 About Kaiser Permanente ...... 3 Dental Coverage ...... 3 Term of this EOC ...... 3 Definitions ...... 4 Premiums, Eligibility, and Enrollment ...... 10 Premiums ...... 10 Who Is Eligible...... 10 When You Can Enroll and When Coverage Begins ...... 12 How to Obtain Services ...... 14 Routine Care ...... 14 Urgent Care ...... 14 Not Sure What Kind of Care You Need? ...... 15 Your Personal Plan Physician ...... 15 Getting a Referral ...... 15 Second Opinions ...... 18 Telehealth Visits ...... 18 Contracts with Plan Providers ...... 18 Receiving Care Outside of your Home Region ...... 19 Your ID Card ...... 19 Timely Access to Care ...... 19 Getting Assistance ...... 20 Plan Facilities ...... 20 Emergency Services and Urgent Care ...... 21 Emergency Services ...... 21 Urgent Care ...... 21 Payment and Reimbursement ...... 22 Benefits and Your Cost Share ...... 22 Your Cost Share ...... 23 Outpatient Care ...... 27 Hospital Inpatient Care ...... 28 Ambulance Services ...... 29 Bariatric Surgery ...... 29 Behavioral Health Treatment for Pervasive Developmental Disorder or Autism ...... 30 Dental and Orthodontic Services ...... 31 Dialysis Care ...... 32 Durable Medical Equipment ("DME") for Home Use ...... 33 Family Planning Services ...... 34 Fertility Services ...... 35 Health Education ...... 35 Hearing Services ...... 35 Home Health Care ...... 36 Hospice Care ...... 37 Mental Health Services ...... 37 Ostomy and Urological Supplies ...... 38 Outpatient Imaging, Laboratory, and Special Procedures ...... 39 Outpatient Prescription Drugs, Supplies, and Supplements ...... 39

Preventive Services ...... 45 Prosthetic and Orthotic Devices ...... 46 Reconstructive Surgery ...... 48 Rehabilitative and Habilitative Services...... 48 Services in Connection with a Clinical Trial ...... 49 Skilled Nursing Facility Care ...... 50 Substance Use Disorder Treatment ...... 50 Transplant Services ...... 51 Vision Services for Adult Members ...... 51 Vision Services for Pediatric Members ...... 52 Exclusions, Limitations, Coordination of Benefits, and Reductions ...... 53 Exclusions ...... 53 Limitations ...... 56 Coordination of Benefits ...... 56 Reductions ...... 57 Post-Service Claims and Appeals ...... 59 Who May File...... 59 Supporting Documents ...... 59 Initial Claims ...... 60 Appeals ...... 61 External Review ...... 61 Additional Review ...... 62 Dispute Resolution ...... 62 Grievances ...... 62 Independent Review Organization for Nonformulary Prescription Drug Requests ...... 64 Department of Managed Health Care Complaints...... 65 Independent Medical Review (IMR) ...... 65 Office of Civil Rights Complaints ...... 66 Additional Review ...... 66 Binding Arbitration ...... 66 Termination of Membership ...... 69 Termination Due to Loss of Eligibility ...... 69 Termination of Agreement ...... 69 Termination for Cause ...... 69 Termination of a Product or all Products...... 69 Payments after Termination ...... 69 State Review of Membership Termination ...... 70 Continuation of Membership ...... 70 Continuation of Group Coverage ...... 70 Uniformed Services Employment and Reemployment Rights Act (USERRA) ...... 73 Coverage for a Disabling Condition ...... 73 Continuation of Coverage under an Individual Plan ...... 73 Miscellaneous Provisions ...... 74 Administration of Agreement ...... 74 Advance Directives ...... 74 Agreement Binding on Members ...... 74 Amendment of Agreement ...... 74 Applications and Statements ...... 74 Assignment ...... 74 Attorney and Advocate Fees and Expenses ...... 74 Claims Review Authority ...... 74

ERISA Notices ...... 74 Governing Law ...... 75 Group and Members Not Our Agents ...... 75 No Waiver ...... 75 Nondiscrimination ...... 75 Notices Regarding Your Coverage ...... 75 Overpayment Recovery ...... 75 Privacy Practices ...... 75 Public Policy Participation ...... 76 Helpful Information ...... 76 How to Obtain this EOC in Other Formats ...... 76 Your Guidebook to Kaiser Permanente Services (Your Guidebook) ...... 76 Online Tools and Resources ...... 76 How to Reach Us ...... 76 Payment Responsibility ...... 78

Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Accumulation Period The Accumulation Period for this plan is 1/1/18 through 12/31/18 (calendar year).

Out-of-Pocket Maximum(s) and Deductible(s) For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. For Services that are subject to the Plan Deductible or the Drug Deductible, you must pay Charges for covered Services you receive during the Accumulation Period until you reach the deductible amounts listed below. All payments you make toward your deductible(s) apply to the Plan Out-of-Pocket Maximum amounts listed below. Family Coverage Family Coverage Self-Only Coverage Amounts per Accumulation Period Each Member in a Family Entire Family of two or (a Family of one Member) of two or more Members more Members Plan Out-of-Pocket Maximum $7,000 $7,000 $14,000 Plan Deductible $1,000 $1,000 $2,000 Drug Deductible $250 $250 $500

Professional Services (Plan Provider office visits) You Pay Most Primary Care Visits and most Non-Physician Specialist Visits ...... $50 per visit (Plan Deductible doesn't apply) Most Physician Specialist Visits ...... $70 per visit (Plan Deductible doesn't apply) Routine physical maintenance exams, including well-woman exams ...... No charge (Plan Deductible doesn't apply) Well-child preventive exams (through age 23 months) ...... No charge (Plan Deductible doesn't apply) Family planning counseling and consultations ...... No charge (Plan Deductible doesn't apply) Scheduled prenatal care exams...... No charge (Plan Deductible doesn't apply) Routine eye exams with a Plan Optometrist...... No charge (Plan Deductible doesn't apply) Urgent care consultations, evaluations, and treatment ...... $50 per visit (Plan Deductible doesn't apply) Most physical, occupational, and speech therapy ...... $65 per visit (Plan Deductible doesn't apply)

Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures ...... 35% Coinsurance after Plan Deductible Allergy injections (including allergy serum) ...... $5 per visit (Plan Deductible doesn't apply) Most immunizations (including the vaccine) ...... No charge (Plan Deductible doesn't apply) Most X-rays ...... $65 per encounter (Plan Deductible doesn't apply) Most laboratory tests ...... $50 per encounter (Plan Deductible doesn't apply) Preventive X-rays, screenings, and laboratory tests as described in this EOC ...... No charge (Plan Deductible doesn't apply) MRI, most CT, and PET scans ...... $350 per procedure after Plan Deductible Covered individual health education counseling ...... No charge (Plan Deductible doesn't apply) Covered health education programs ...... No charge (Plan Deductible doesn't apply)

Hospitalization Services You Pay Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs . 35% Coinsurance after Plan Deductible

Emergency Health Coverage You Pay Emergency Department visits ...... 35% Coinsurance after Plan Deductible Note: This Cost Share does not apply if you are admitted directly to the hospital as an inpatient for covered Services (see "Hospitalization Services" for inpatient Cost Share). Ambulance Services You Pay Ambulance Services ...... 35% Coinsurance after Plan Deductible

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Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines: Most generic items at a Plan Pharmacy ...... $25 for up to a 30-day supply (Drug Deductible doesn't apply) Most generic refills through our mail-order service ...... $50 for up to a 100-day supply (Drug Deductible doesn't apply) Most brand-name items at a Plan Pharmacy ...... $70 for up to a 30-day supply after Drug Deductible Most brand-name refills through our mail-order service ...... $140 for up to a 100-day supply after Drug Deductible Most specialty items at a Plan Pharmacy ...... 20% Coinsurance (not to exceed $250) for up to a 30-day supply after Drug Deductible

Durable Medical Equipment (DME) You Pay Base DME items as described in this EOC (most DME not covered) ...... 35% Coinsurance (Plan Deductible doesn't apply)

Mental Health Services You Pay Inpatient psychiatric hospitalization ...... 35% Coinsurance after Plan Deductible Individual outpatient mental health evaluation and treatment ...... $50 per visit (Plan Deductible doesn't apply) Group outpatient mental health treatment ...... $25 per visit (Plan Deductible doesn't apply)

Substance Use Disorder Treatment You Pay Inpatient detoxification ...... 35% Coinsurance after Plan Deductible Individual outpatient substance use disorder evaluation and treatment ...... $50 per visit (Plan Deductible doesn't apply) Group outpatient substance use disorder treatment ...... $5 per visit (Plan Deductible doesn't apply)

Home Health Services You Pay Home health care (up to 100 visits per Accumulation Period) ...... No charge (Plan Deductible doesn't apply)

Other You Pay Eyeglasses or contact lenses for Pediatric Members: One complete pair of eyeglasses (frames and lenses) or one pair of contact lenses per Accumulation Period, as described in this EOC ..... No charge (Plan Deductible doesn't apply) Skilled Nursing Facility care (up to 100 days per benefit period) ...... 35% Coinsurance after Plan Deductible Prosthetic and orthotic devices as described in this EOC ...... No charge (Plan Deductible doesn't apply) Hospice care ...... No charge (Plan Deductible doesn't apply)

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of- pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the "Benefits and Your Cost Share" and "Exclusions, Limitations, Coordination of Benefits, and Reductions" sections.

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Introduction your Home Region. When you visit the other California Region, you may receive care as described in "Receiving Care Outside of your Home Region" in the "How to This combined Disclosure Form and Evidence of Obtain Services" section. Coverage ("EOC") describes the health care coverage of Kaiser Permanente Silver 70 HMO 1000/50 Alt provided Kaiser Permanente provides Services directly to our under the Group Agreement (Agreement) between Health Members through an integrated medical care program. Plan (Kaiser Foundation Health Plan, Inc.), Covered Health Plan, Plan Hospitals, and the Medical Group California for Small Business, and your Group. work together to provide our Members with quality care. Our medical care program gives you access to all of the This EOC is part of the Agreement between covered Services you may need, such as routine care Health Plan, Covered California for Small with your own personal Plan Physician, hospital care, Business, and your Group. The Agreement laboratory and pharmacy Services, Emergency Services, contains additional terms such as Premiums, Urgent Care, and other benefits described in this EOC. when coverage can change, the effective date Plus, our health education programs offer you great ways to protect and improve your health. of coverage, and the effective date of termination. The Agreement must be consulted We provide covered Services to Members using Plan to determine the exact terms of coverage. A Providers located in your Home Region Service Area, copy of the Agreement is available from which is described in the "Definitions" section. You must receive all covered care from Plan Providers inside your Covered California for Small Business. Home Region Service Area, except as described in the sections listed below for the following Services: For benefits provided under any other Health Plan program, refer to that plan's evidence of coverage. For • Authorized referrals as described under "Getting a benefits provided under any other program offered by Referral" in the "How to Obtain Services" section your Group (for example, workers compensation • Emergency ambulance Services as described under benefits), refer to your Group's materials. "Ambulance Services" in the "Benefits and Your Cost Share" section In this EOC, Health Plan is sometimes referred to as • Emergency Services, Post-Stabilization Care, and "we" or "us." Members are sometimes referred to as Out-of-Area Urgent Care as described in the "you." Some capitalized terms have special meaning in "Emergency Services and Urgent Care" section this EOC; please see the "Definitions" section for terms you should know. • Hospice care as described under "Hospice Care" in the "Benefits and Your Cost Share" section It is important to familiarize yourself with your coverage • Visiting Member Services as described under by reading this EOC completely, so that you can take full "Receiving Care Outside of your Home Region" in advantage of your Health Plan benefits. Also, if you have the "How to Obtain Services" section special health care needs, please carefully read the sections that apply to you. Dental Coverage About Kaiser Permanente Dental services are not covered under this EOC, except as described under "Dental and Orthodontic Services" in PLEASE READ THE FOLLOWING the "Benefits and Your Cost Share" section. The INFORMATION SO THAT YOU WILL KNOW information in this EOC, such as how to get care, FROM WHOM OR WHAT GROUP OF services that are covered, and how to resolve issues PROVIDERS YOU MAY GET HEALTH CARE. related to your health care coverage, pertains only to the Services that are covered under this EOC. When you join Kaiser Permanente, you are enrolling in one of two Health Plan Regions in California (either our Northern California Region or Southern California Term of this EOC Region), which we call your "Home Region." The This EOC is for contract year 2018 (a 12-month period), Service Area of each Region is described in the unless amended. For example, if your Group's coverage "Definitions" section of this EOC. The coverage is effective January 1, 2018, the term of this EOC is the information in this EOC applies when you obtain care in period January 1, 2018, through December 31, 2018.

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Your Group can tell you the effective date of coverage payment, the amount Kaiser Permanente would have and whether this EOC is still in effect and give you a paid if it did not subtract your Cost Share current one if this EOC has expired or been amended. Coinsurance: A percentage of Charges that you must pay when you receive a covered Service under this EOC. Copayment: A specific dollar amount that you must pay Definitions when you receive a covered Service under this EOC. Note: The dollar amount of the Copayment can be $0 Some terms have special meaning in this EOC. When we (no charge). use a term with special meaning in only one section of this EOC, we define it in that section. The terms in this Cost Share: The amount you are required to pay for "Definitions" section have special meaning when covered Services. For example, your Cost Share may be capitalized and used in any section of this EOC. a Copayment or Coinsurance. If your coverage includes a Plan Deductible and you receive Services that are subject Accumulation Period: A period of time no greater than to the Plan Deductible, your Cost Share for those 12 consecutive months for purposes of accumulating Services will be Charges until you reach the Plan amounts toward any deductibles (if applicable) and out- Deductible. Similarly, if your coverage includes a Drug of-pocket maximums. For example, the Accumulation Deductible, and you receive Services that are subject to Period may be a calendar year or contract year. The the Drug Deductible, your Cost Share for those Services Accumulation Period for this EOC is from January 1, will be Charges until you reach the Drug Deductible. 2018, through December 31, 2018. Dependent: A Member who meets the eligibility Adult Member: A Member who is age 19 or older and requirements as a Dependent (for Dependent eligibility is not a Pediatric Member. For example, if you turn 19 requirements, see "Who Is Eligible" in the "Premiums, on June 25, you will be an Adult Member starting July 1. Eligibility, and Enrollment" section). Allowance: A specified amount that you can use toward Disclosure Form (DF): A summary of coverage for the purchase price of an item. If the price of the item(s) prospective Members. For some products, the DF is you select exceeds the Allowance, you will pay the combined with the evidence of coverage. amount in excess of the Allowance (and that payment will not apply toward any deductible or out-of-pocket Drug Deductible: The amount you must pay in the maximum). Accumulation Period for certain drugs, supplies, and supplements before we will cover those Services at the Charges: "Charges" means the following: applicable Copayment or Coinsurance in that • For Services provided by the Medical Group or Accumulation Period. Please refer to the "Outpatient Kaiser Foundation Hospitals, the charges in Health Prescription Drugs, Supplies, and Supplements" section Plan's schedule of Medical Group and Kaiser to learn whether your coverage includes a Drug Foundation Hospitals charges for Services provided Deductible, the Services that are subject to the Drug to Members Deductible, and the Drug Deductible amount. • For Services for which a provider (other than the Emergency Medical Condition: A medical condition Medical Group or Kaiser Foundation Hospitals) is manifesting itself by acute symptoms of sufficient compensated on a capitation basis, the charges in the severity (including severe pain) such that a reasonable schedule of charges that Kaiser Permanente person would have believed that the absence of negotiates with the capitated provider immediate medical attention would result in any of the • For items obtained at a pharmacy owned and operated following: by Kaiser Permanente, the amount the pharmacy • Placing the person's health (or, with respect to a would charge a Member for the item if a Member's pregnant woman, the health of the woman or her benefit plan did not cover the item (this amount is an unborn child) in serious jeopardy estimate of: the cost of acquiring, storing, and • Serious impairment to bodily functions dispensing drugs, the direct and indirect costs of providing Kaiser Permanente pharmacy Services to • Serious dysfunction of any bodily organ or part Members, and the pharmacy program's contribution to the net revenue requirements of Health Plan) • For all other Services, the payments that Kaiser Permanente makes for the Services or, if Kaiser Permanente subtracts your Cost Share from its

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A mental health condition is an Emergency Medical Medically Necessary: A Service is Medically Necessary Condition when it meets the requirements of the if it is medically appropriate and required to prevent, paragraph above, or when the condition manifests itself diagnose, or treat your condition or clinical symptoms in by acute symptoms of sufficient severity such that either accord with generally accepted professional standards of of the following is true: practice that are consistent with a standard of care in the • The person is an immediate danger to himself or medical community. herself or to others Medicare: The federal health insurance program for • The person is immediately unable to provide for, or people 65 years of age or older, some people under age use, food, shelter, or clothing, due to the mental 65 with certain disabilities, and people with end-stage disorder renal disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). For Emergency Services: All of the following with respect purposes of describing Medicare coverage in this EOC, to an Emergency Medical Condition: Members who are "eligible for" Medicare Part A or B are • A medical screening exam that is within the those who would qualify for Medicare Part A or B capability of the emergency department of a hospital, coverage if they were to apply for it. Members who including ancillary services (such as imaging and "have" Medicare Part A or B are those who have been laboratory Services) routinely available to the granted Medicare Part A or B coverage. emergency department to evaluate the Emergency Member: A person who is eligible and enrolled under Medical Condition this EOC, and for whom we have received applicable • Within the capabilities of the staff and facilities Premiums. This EOC sometimes refers to a Member as available at the hospital, Medically Necessary "you." examination and treatment required to Stabilize the Non-Physician Specialist Visits: Consultations, patient (once your condition is Stabilized, Services evaluations, and treatment by non-physician specialists you receive are Post Stabilization Care and not (such as nurse practitioners, physician assistants, Emergency Services) optometrists, podiatrists, and audiologists). EOC: This Combined Disclosure Form and Evidence of Non–Plan Hospital: A hospital other than a Plan Coverage document, including any amendments, which Hospital. describes the health care coverage of "Kaiser Permanente Deductible HMO Plan" under Health Plan's Agreement Non–Plan Physician: A physician other than a Plan with your Group. Physician. Family: A Subscriber and all of his or her Dependents. Non–Plan Provider: A provider other than a Plan Provider. Group: The entity with which Health Plan has entered into the Agreement that includes this EOC. Non–Plan Psychiatrist: A psychiatrist who is not a Plan Physician. Health Plan: Kaiser Foundation Health Plan, Inc., a California nonprofit corporation. Health Plan is a health Out-of-Area Urgent Care: Medically Necessary care service plan licensed to offer health care coverage Services to prevent serious deterioration of your (or your by the Department of Managed Health Care. This EOC unborn child's) health resulting from an unforeseen sometimes refers to Health Plan as "we" or "us." illness, unforeseen injury, or unforeseen complication of an existing condition (including pregnancy) if all of the The Region where you enrolled (either Home Region: following are true: the Northern California Region or the Southern California Region). • You are temporarily outside your Home Region Service Area Kaiser Permanente: Kaiser Foundation Hospitals (a California nonprofit corporation), Health Plan, and the • A reasonable person would have believed that your Medical Group. (or your unborn child's) health would seriously deteriorate if you delayed treatment until you returned Medical Group: For Northern California Region to your Home Region Service Area Members, The Permanente Medical Group, Inc., a for- profit professional corporation, and for Southern Pediatric Member: A Member from birth through the California Region Members, the Southern California end of the month of his or her 19th birthday. For Permanente Medical Group, a for-profit professional example, if you turn 19 on June 25, you will be an Adult partnership. Member starting July 1 and your last minute as a Pediatric Member will be 11:59 p.m. on June 30.

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Physician Specialist Visits: Consultations, evaluations, Pharmacies in your area, except that Plan Pharmacies are and treatment by physician specialists, including subject to change at any time without notice. For the personal Plan Physicians who are not Primary Care current locations of Plan Pharmacies, please call our Physicians. Member Service Contact Center. Plan Deductible: The amount you must pay in the Plan Physician: Any licensed physician who is a partner Accumulation Period for certain Services before we will or employee of the Medical Group, or any licensed cover those Services at the applicable Copayment or physician who contracts to provide Services to Members Coinsurance in that Accumulation Period. Please refer to (but not including physicians who contract only to the "Benefits and Your Cost Share" section to learn provide referral Services). whether your coverage includes a Plan Deductible, the Plan Provider: A Plan Hospital, a Plan Physician, the Services that are subject to the Plan Deductible, and the Medical Group, a Plan Pharmacy, or any other health Plan Deductible amount. care provider that Health Plan designates as a Plan Plan Facility: Any facility listed on our website at Provider. kp.org/facilities for your Home Region Service Area, Plan Skilled Nursing Facility: A Skilled Nursing except that Plan Facilities are subject to change at any Facility approved by Health Plan. time without notice. For the current locations of Plan Facilities, please call our Member Service Contact Post-Stabilization Care: Medically Necessary Services Center. related to your Emergency Medical Condition that you receive in a hospital (including the Emergency Plan Hospital: Any hospital listed on our website at Department) after your treating physician determines that kp.org/facilities for your Home Region Service Area, this condition is Stabilized. except that Plan Hospitals are subject to change at any time without notice. For the current locations of Plan Premiums: The periodic amounts that your Group is Hospitals, please call our Member Service Contact responsible for paying for your membership under this Center. EOC, except that you are responsible for paying Premiums if you have Cal-COBRA coverage. Plan Medical Office: Any medical office listed on our website at kp.org/facilities for your Home Region Preventive Services: Covered Services that prevent or Service Area, except that Plan Medical Offices are detect illness and do one or more of the following: subject to change at any time without notice. For the • Protect against disease and disability or further current locations of Plan Medical Offices, please call our progression of a disease Member Service Contact Center. • Detect disease in its earliest stages before noticeable Plan Optical Sales Office: An optical sales office symptoms develop owned and operated by Kaiser Permanente or another optical sales office that we designate. Please refer to Primary Care Physicians: Generalists in internal Your Guidebook for a list of Plan Optical Sales Offices medicine, pediatrics, and family practice, and specialists in your area, except that Plan Optical Sales Offices are in obstetrics/gynecology whom the Medical Group subject to change at any time without notice. For the designates as Primary Care Physicians. Please refer to current locations of Plan Optical Sales Offices, please our website at kp.org for a directory of Primary Care call our Member Service Contact Center. Physicians, except that the directory is subject to change without notice. For the current list of physicians that are Plan Optometrist: An optometrist who is a Plan available as Primary Care Physicians, please call the Provider. personal physician selection department at the phone Plan Out-of-Pocket Maximum: The total amount of number listed in Your Guidebook. Cost Share you must pay under this EOC in the Primary Care Visits: Evaluations and treatment Accumulation Period for certain covered Services that provided by Primary Care Physicians and primary care you receive in the same Accumulation Period. Please Plan Providers who are not physicians (such as nurse refer to the "Benefits and Your Cost Share" section to practitioners). find your Plan Out-of-Pocket Maximum amount and to learn which Services apply to the Plan Out-of-Pocket Region: A Kaiser Foundation Health Plan organization Maximum. or allied plan that conducts a direct-service health care program. Regions may change on January 1 of each year Plan Pharmacy: A pharmacy owned and operated by and are currently the District of Columbia and parts of Kaiser Permanente or another pharmacy that we Northern California, Southern California, Colorado, designate. Please refer to Your Guidebook or the facility Georgia, Hawaii, Idaho, Maryland, Oregon, Virginia, directory on our website at kp.org for a list of Plan and Washington. For the current list of Region locations,

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please visit our website at kp.org or call our Member 14, 95619, 95623, 95633–35, 95651, 95664, 95667, Service Contact Center. 95672, 95682, 95762 Serious Emotional Disturbance of a Child Under Age • The following ZIP codes in Fresno County are inside 18: A condition identified as a "mental disorder" in the our Northern California Service Area: 93242, 93602, most recent edition of the Diagnostic and Statistical 93606–07, 93609, 93611–13, 93616, 93618–19, Manual of Mental Disorders, other than a primary 93624–27, 93630–31, 93646, 93648–52, 93654, substance use disorder or developmental disorder, that 93656–57, 93660, 93662, 93667–68, 93675, 93701– results in behavior inappropriate to the child's age 12, 93714–18, 93720–30, 93737, 93740–41, 93744– according to expected developmental norms, if the child 45, 93747, 93750, 93755, 93760–61, 93764–65, also meets at least one of the following three criteria: 93771–79, 93786, 93790–94, 93844, 93888 • As a result of the mental disorder, (1) the child has • The following ZIP codes in Kings County are inside substantial impairment in at least two of the following our Northern California Service Area: 93230, 93232, areas: self-care, school functioning, family 93242, 93631, 93656 relationships, or ability to function in the community; • The following ZIP codes in Madera County are inside and (2) either (a) the child is at risk of removal from our Northern California Service Area: 93601–02, the home or has already been removed from the 93604, 93614, 93623, 93626, 93636–39, 93643–45, home, or (b) the mental disorder and impairments 93653, 93669, 93720 have been present for more than six months or are likely to continue for more than one year without • All ZIP codes in Marin County are inside our treatment Northern California Service Area: 94901, 94903–04, 94912–15, 94920, 94924–25, 94929–30, 94933, • The child displays psychotic features, or risk of 94937–42, 94945–50, 94956–57, 94960, 94963–66, suicide or violence due to a mental disorder 94970–71, 94973–74, 94976–79 • The child meets special education eligibility • The following ZIP codes in Mariposa County are requirements under Section 5600.3(a)(2)(C) of the inside our Northern California Service Area: 93601, Welfare and Institutions Code 93623, 93653 Service Area: Health Plan has two Regions in • All ZIP codes in Napa County are inside our Northern California. As a Member, you are enrolled in one of the California Service Area: 94503, 94508, 94515, two Regions (either our Northern California Region or 94558–59, 94562, 94567, 94573–74, 94576, 94581, Southern California Region), called your Home Region. 94599, 95476 This EOC describes the coverage for both California • The following ZIP codes in Placer County are inside Regions. our Northern California Service Area: 95602–04, 95610, 95626, 95648, 95650, 95658, 95661, 95663, Northern California Region Service Area 95668, 95677–78, 95681, 95703, 95722, 95736, The ZIP codes below for each county are in our Northern 95746–47, 95765 California Service Area: • All ZIP codes in Sacramento County are inside our • All ZIP codes in Alameda County are inside our Northern California Service Area: 94203–09, 94211, Northern California Service Area: 94501–02, 94505, 94229–30, 94232, 94234–37, 94239–40, 94244, 94514, 94536–46, 94550–52, 94555, 94557, 94560, 94247–50, 94252, 94254, 94256–59, 94261–63, 94566, 94568, 94577–80, 94586–88, 94601–15, 94267–69, 94271, 94273–74, 94277–80, 94282–85, 94617–21, 94622–24, 94649, 94659–62, 94666, 94287–91, 94293–98, 94571, 95608–11, 95615, 94701–10, 94712, 94720, 95377, 95391 95621, 95624, 95626, 95628, 95630, 95632, 95638– • The following ZIP codes in Amador County are 39, 95641, 95652, 95655, 95660, 95662, 95670–71, inside our Northern California Service Area: 95640, 95673, 95678, 95680, 95683, 95690, 95693, 95741– 95669 42, 95757–59, 95763, 95811–38, 95840–43, 95851– 53, 95860, 95864–67, 95894, 95899 • All ZIP codes in Contra Costa County are inside our • Northern California Service Area: 94505–07, 94509, All ZIP codes in San Francisco County are inside our 94511, 94513–14, 94516–31, 94547–49, 94551, Northern California Service Area: 94102–05, 94107– 94553, 94556, 94561, 94563–65, 94569–70, 94572, 12, 94114–27, 94129–34, 94137, 94139–47, 94151, 94575, 94582–83, 94595–98, 94706–08, 94801–08, 94158–61, 94163–64, 94172, 94177, 94188 94820, 94850 • All ZIP codes in San Joaquin County are inside our • The following ZIP codes in El Dorado County are Northern California Service Area: 94514, 95201–15, inside our Northern California Service Area: 95613– 95219–20, 95227, 95230–31, 95234, 95236–37,

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95240–42, 95253, 95258, 95267, 95269, 95296–97, Southern California Region Service Area 95304, 95320, 95330, 95336–37, 95361, 95366, The ZIP codes below for each county are in our Southern 95376–78, 95385, 95391, 95632, 95686, 95690 California Service Area: • All ZIP codes in San Mateo County are inside our • The following ZIP codes in Imperial County are Northern California Service Area: 94002, 94005, inside our Southern California Service Area: 92274– 94010–11, 94014–21, 94025–28, 94030, 94037–38, 75 94044, 94060–66, 94070, 94074, 94080, 94083, 94128, 94303, 94401–04, 94497 • The following ZIP codes in Kern County are inside our Southern California Service Area: 93203, 93205– • The following ZIP codes in Santa Clara County are 06, 93215–16, 93220, 93222, 93224–26, 93238, inside our Northern California Service Area: 94022– 93240–41, 93243, 93249–52, 93263, 93268, 93276, 24, 94035, 94039–43, 94085–89, 94301–06, 94309, 93280, 93285, 93287, 93301–09, 93311–14, 93380, 94550, 95002, 95008–09, 95011, 95013–15, 95020– 93383–90, 93501–02, 93504–05, 93518–19, 93531, 21, 95026, 95030–33, 95035–38, 95042, 95044, 93536, 93560–61, 93581 95046, 95050–56, 95070–71, 95076, 95101, 95103, 95106, 95108–13, 95115–36, 95138–41, 95148, • The following ZIP codes in Los Angeles County are 95150–61, 95164, 95170, 95172–73, 95190–94, inside our Southern California Service Area: 90001– 95196 84, 90086–91, 90093–96, 90099, 90189, 90201–02, 90209–13, 90220–24, 90230–33, 90239–42, 90245, • All ZIP codes in Santa Cruz County are inside our 90247–51, 90254–55, 90260–67, 90270, 90272, Northern California Service Area: 95001, 95003, 90274–75, 90277–78, 90280, 90290–96, 90301–12, 95005–7, 95010, 95017–19, 95033, 95041, 95060– 90401–11, 90501–10, 90601–10, 90623, 90630–31, 67, 95073, 95076–77 90637–40, 90650–52, 90660–62, 90670–71, 90701– • All ZIP codes in Solano County are inside our 03, 90706–07, 90710–17, 90723, 90731–34, 90744– Northern California Service Area: 94503, 94510, 49, 90755, 90801–10, 90813–15, 90822, 90831–35, 94512, 94533–35, 94571, 94585, 94589–92, 95616, 90840, 90842, 90844, 90846–48, 90853, 90895, 95618, 95620, 95625, 95687–88, 95690, 95694, 90899, 91001, 91003, 91006–12, 91016–17, 91020– 95696 21, 91023–25, 91030–31, 91040–43, 91046, 91066, • The following ZIP codes in Sonoma County are 91077, 91101–10, 91114–18, 91121, 91123–26, inside our Northern California Service Area: 94515, 91129, 91182, 91184–85, 91188–89, 91199, 91201– 94922–23, 94926–28, 94931, 94951–55, 94972, 10, 91214, 91221–22, 91224–26, 91301–11, 91313, 94975, 94999, 95401–07, 95409, 95416, 95419, 91316, 91321–22, 91324–31, 91333–35, 91337, 95421, 95425, 95430–31, 95433, 95436, 95439, 91340–46, 91350–57, 91361–62, 91364–65, 91367, 95441–42, 95444, 95446, 95448, 95450, 95452, 91371–72, 91376, 91380–87, 91390, 91392–96, 95462, 95465, 95471–73, 95476, 95486–87, 95492 91401–13, 91416, 91423, 91426, 91436, 91470, 91482, 91495–96, 91499, 91501–08, 91510, 91521– • All ZIP codes in Stanislaus County are inside our 23, 91526, 91601–12, 91614–18, 91702, 91706, Northern California Service Area: 95230, 95304, 91711, 91714–16, 91722–24, 91731–35, 91740–41, 95307, 95313, 95316, 95319, 95322–23, 95326, 91744–50, 91754–56, 91759, 91765–73, 91775–76, 95328–29, 95350–58, 95360–61, 95363, 95367–68, 91778, 91780, 91788–93, 91801–04, 91896, 91899, 95380–82, 95385–87, 95397 93243, 93510, 93532, 93534–36, 93539, 93543–44, • The following ZIP codes in Sutter County are inside 93550–53, 93560, 93563, 93584, 93586, 93590–91, our Northern California Service Area: 95626, 95645, 93599 95659, 95668, 95674, 95676, 95692, 95836–37 • All ZIP codes in Orange County are inside our • The following ZIP codes in Tulare County are inside Southern California Service Area: 90620–24, 90630– our Northern California Service Area: 93618, 93631, 33, 90638, 90680, 90720–21, 90740, 90742–43, 93646, 93654, 93666, 93673 92602–07, 92609–10, 92612, 92614–20, 92623–30, 92637, 92646–63, 92672–79, 92683–85, 92688, • The following ZIP codes in Yolo County are inside 92690–94, 92697–98, 92701–08, 92711–12, 92728, our Northern California Service Area: 95605, 95607, 92735, 92780–82, 92799, 92801–09, 92811–12, 95612, 95615–18, 95645, 95691, 95694–95, 95697– 92814–17, 92821–23, 92825, 92831–38, 92840–46, 98, 95776, 95798–99 92850, 92856–57, 92859, 92861–71, 92885–87, • The following ZIP codes in Yuba County are inside 92899 our Northern California Service Area: 95692, 95903, • The following ZIP codes in Riverside County are 95961 inside our Southern California Service Area: 91752,

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92028, 92201–03, 92210–11, 92220, 92223, 92230, "Behavioral Health Treatment for Pervasive 92234–36, 92240–41, 92247–48, 92253–55, 92258, Developmental Disorder or Autism" in the "Benefits and 92260–64, 92270, 92274, 92276, 92282, 92320, Your Cost Share" section, and services to treat Severe 92324, 92373, 92399, 92501–09, 92513–14, 92516– Mental Illness or Serious Emotional Disturbance of a 19, 92521–22, 92530–32, 92543–46, 92548, 92551– Child Under Age 18. 57, 92562–64, 92567, 92570–72, 92581–87, 92589– Severe Mental Illness: The following mental disorders: 93, 92595–96, 92599, 92860, 92877–83 schizophrenia, schizoaffective disorder, bipolar disorder • The following ZIP codes in San Bernardino County (manic-depressive illness), major depressive disorders, are inside our Southern California Service Area: panic disorder, obsessive-compulsive disorder, pervasive 91701, 91708–10, 91729–30, 91737, 91739, 91743, developmental disorder or autism, anorexia nervosa, or 91758–59, 91761–64, 91766, 91784–86, 91792, bulimia nervosa. 92252, 92256, 92268, 92277–78, 92284–86, 92305, 92307–08, 92313–18, 92321–22, 92324–25, 92329, Skilled Nursing Facility: A facility that provides 92331, 92333–37, 92339–41, 92344–46, 92350, inpatient skilled nursing care, rehabilitation services, or 92352, 92354, 92357–59, 92369, 92371–78, 92382, other related health services and is licensed by the state 92385–86, 92391–95, 92397, 92399, 92401–08, of California. The facility's primary business must be the 92410–11, 92413, 92415, 92418, 92423, 92427, provision of 24-hour-a-day licensed skilled nursing care. 92880 The term "Skilled Nursing Facility" does not include convalescent nursing homes, rest facilities, or facilities • The following ZIP codes in San Diego County are for the aged, if those facilities furnish primarily custodial inside our Southern California Service Area: 91901– care, including training in routines of daily living. A 03, 91908–17, 91921, 91931–33, 91935, 91941–46, "Skilled Nursing Facility" may also be a unit or section 91950–51, 91962–63, 91976–80, 91987, 92003, within another facility (for example, a hospital) as long 92007–11, 92013–14, 92018–30, 92033, 92037–40, as it continues to meet this definition. 92046, 92049, 92051–52, 92054–61, 92064–65, 92067–69, 92071–72, 92074–75, 92078–79, 92081– Spouse: The person to whom the Subscriber is legally 86, 92088, 92091–93, 92096, 92101–24, 92126–32, married under applicable law. For the purposes of this 92134–40, 92142–43, 92145, 92147, 92149–50, EOC, the term "Spouse" includes the Subscriber's 92152–55, 92158–61, 92163, 92165–79, 92182, domestic partner. "Domestic partners" are two people 92186–87, 92190–93, 92195–99 who are registered and legally recognized as domestic partners by California (if your Group allows enrollment • The following ZIP codes in Tulare County are inside of domestic partners not legally recognized as domestic our Southern California Service Area: 93238, 93261 partners by California, "Spouse" also includes the • The following ZIP codes in Ventura County are Subscriber's domestic partner who meets your Group's inside our Southern California Service Area: 90265, eligibility requirements for domestic partners). 91304, 91307, 91311, 91319–20, 91358–62, 91377, Stabilize: To provide the medical treatment of the 93001–07, 93009–12, 93015–16, 93020–22, 93030– Emergency Medical Condition that is necessary to 36, 93040–44, 93060–66, 93094, 93099, 93252 assure, within reasonable medical probability, that no For each ZIP code listed for a county, your Home Region material deterioration of the condition is likely to result Service Area includes only the part of that ZIP code that from or occur during the transfer of the person from the is in that county. When a ZIP code spans more than one facility. With respect to a pregnant woman who is having county, the part of that ZIP code that is in another county contractions, when there is inadequate time to safely is not inside your Home Region Service Area unless that transfer her to another hospital before delivery (or the other county is listed above and that ZIP code is also transfer may pose a threat to the health or safety of the listed for that other county. woman or unborn child), "Stabilize" means to deliver (including the placenta). If you have a question about whether a ZIP code is in your Home Region Service Area, please call our Member Subscriber: A Member who is eligible for membership Service Contact Center. on his or her own behalf and not by virtue of Dependent status and who meets the eligibility requirements as a Note: We may expand your Home Region Service Area Subscriber (for Subscriber eligibility requirements, see at any time by giving written notice to your Group. ZIP "Who Is Eligible" in the "Premiums, Eligibility, and codes are subject to change by the U.S. Postal Service. Enrollment" section). Services: Health care services or items ("health care" Telehealth Visits: Interactive video visits and scheduled includes both physical health care and mental health telephone visits between you and your provider. care), behavioral health treatment covered under

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Urgent Care: Medically Necessary Services for a Subscribers must live or work inside your Home Region condition that requires prompt medical attention but is Service Area at the time they enroll. If after enrollment not an Emergency Medical Condition. the Subscriber no longer lives or works inside your Home Region Service Area, the Subscriber can continue membership unless (1) he or she lives inside or moves to the service area of another Region and does not work Premiums, Eligibility, and inside your Home Region Service Area, or (2) your Enrollment Group does not allow continued enrollment of Subscribers who do not live or work inside your Home Premiums Region Service Area.

Your Group is responsible for paying Premiums, except Dependent children of the Subscriber or of the that you are responsible for paying Premiums as Subscriber's Spouse may live anywhere inside or outside described in the "Continuation of Membership" section your Home Region Service Area. Other Dependents may if you have Cal-COBRA coverage under this EOC. live anywhere, except that they are not eligible to enroll If you are responsible for any contribution to the or to continue enrollment if they live in or move to the Premiums that your Group pays, your Group will tell you service area of another Region. the amount, when Premiums are effective, and how to pay your Group (through payroll deduction, for If you are not eligible to continue enrollment because example). you live in or move to the service area of another Region, please contact your Group to learn about your Group health care options: Who Is Eligible • Regions outside California. You may be able to To enroll and to continue enrollment, you must meet all enroll in the service area of another Region if there is of the eligibility requirements described in this "Who Is an agreement between your Group and that Region, Eligible" section, including Covered California eligibility but the plan, including coverage, premiums, and requirements, your Group's eligibility requirements, and eligibility requirements, might not be the same as our Service Area eligibility requirements. under this EOC • The other California Region's Service Area. If the Covered California for Small Business (CCSB) Subscriber moves from your Home Region to the eligibility requirements other California Region, your Group may permit you If your coverage is through CCSB, you must meet to enroll in that Region. If your Group permits eligibility requirements established by CCSB. enrollment and the Subscriber does not submit a new Information regarding eligibility requirements and how enrollment form, all terms and conditions in your to appeal eligibility determinations can be found in the application for enrollment in your Home Region, "Kaiser Permanente group service agreement" on including the Arbitration Agreement, will continue to Covered California's website at apply www.coveredca.com/forsmallbusiness/. Questions about CCSB eligibility requirements should be directed For more information about the service areas of the other to CCSB. Regions, please call our Member Service Contact Center.

Group eligibility requirements Eligibility as a Subscriber You must meet your Group's eligibility requirements, You may be eligible to enroll and continue enrollment as such as the minimum number of hours that employees a Subscriber if you are: must work. Your Group is required to inform Subscribers • of its eligibility requirements. An employee of your Group • A proprietor or partner of your Group Service Area eligibility requirements • Otherwise entitled to coverage under a trust When you join Kaiser Permanente, you are enrolling in agreement or employment contract (unless the one of two Health Plan Regions in California (either our Internal Revenue Service considers you self- Northern California Region or Southern California employed) Region), which we call your "Home Region." The Service Area of each Region is described in the "Definitions" section.

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Newborn coverage Age limit of Dependent children. Children must be If you are already enrolled under this EOC and have a under age 26 to enroll as a Dependent under your plan. baby, your newborn will automatically be covered for 31 Dependent children are eligible to remain on the plan days from the date of birth. If you do not enroll the through the end of the month in which they reach the age newborn within 60 days, he or she is covered for only 31 limit. Dependent children of the Subscriber or Spouse days (including the date of birth). (including adopted children and children placed with you for adoption) who reach the age limit may continue Eligibility as a Dependent coverage under this EOC if all of the following Enrolling as a Dependent. Dependent eligibility is conditions are met: subject to your Group's eligibility requirements, which • They meet all requirements to be a Dependent except are not described in this EOC. You can obtain your for the age limit Group's eligibility requirements directly from your • Your Group permits enrollment of Dependents Group. If you are a Subscriber under this EOC and if your Group allows enrollment of Dependents, Health • They are incapable of self-sustaining employment Plan allows the following persons to enroll as your because of a physically- or mentally-disabling injury, Dependents under this EOC: illness, or condition that occurred before they reached the age limit for Dependents • Your Spouse • They receive 50 percent or more of their support and • Your or your Spouse's Dependent children, who meet maintenance from you or your Spouse the requirements described under "Age limit of Dependent children," if they are any of the following: • You give us proof of their incapacity and dependency within 60 days after we request it (see "Disabled ♦ sons, daughters, or stepchildren Dependent certification" below in this "Eligibility as ♦ adopted children a Dependent" section) ♦ children placed with you for adoption ♦ children for whom you or your Spouse is the Disabled Dependent certification. One of the court-appointed guardian (or was when the child requirements for a Dependent to be eligible to continue reached age 18) coverage as a disabled Dependent is that the Subscriber must provide us documentation of the dependent's • Children whose parent is a Dependent under your incapacity and dependency as follows: family coverage (including adopted children and children placed with your Dependent for adoption) • If the child is a Member, we will send the Subscriber if they meet all of the following requirements: a notice of the Dependent's membership termination ♦ they are not married and do not have a domestic due to loss of eligibility at least 90 days before the partner (for the purposes of this requirement only, date coverage will end due to reaching the age limit. "domestic partner" means someone who is The Dependent's membership will terminate as registered and legally recognized as a domestic described in our notice unless the Subscriber provides partner by California) us documentation of the Dependent's incapacity and dependency within 60 days of receipt of our notice ♦ they meet the requirements described under "Age and we determine that the Dependent is eligible as a limit of Dependent children" disabled dependent. If the Subscriber provides us this ♦ they receive all of their support and maintenance documentation in the specified time period and we do from you or your Spouse not make a determination about eligibility before the ♦ they permanently reside with you or your Spouse termination date, coverage will continue until we make a determination. If we determine that the • Children placed with the Subscriber or Spouse for Dependent does not meet the eligibility requirements foster care who enroll during a special enrollment as a disabled dependent, we will notify the Subscriber period triggered by the placement of that child in that the Dependent is not eligible and let the foster care Subscriber know the membership termination date. • Persons (but not including foster children) who meet If we determine that the Dependent is eligible as a both of the following requirements: disabled dependent, there will be no lapse in ♦ they receive 50 percent or more of their support coverage. Also, starting two years after the date that and maintenance from you or your Spouse the Dependent reached the age limit, the Subscriber ♦ they are related to you or your Spouse by blood or must provide us documentation of the Dependent's marriage, or they permanently live with you or incapacity and dependency annually within 60 days your Spouse after we request it so that we can determine if the

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Dependent continues to be eligible as a disabled eligible Dependents by submitting a Health Plan– dependent approved enrollment application to your Group within 30 • If the child is not a Member because you are days. changing coverages, you must give us proof, within 60 days after we request it, of the child's incapacity Effective date of coverage. The effective date of and dependency as well as proof of the child's coverage for new employees and their eligible family coverage under your prior coverage. In the future, Dependents is determined by your Group in accord with you must provide proof of the child's continued waiting period requirements in state and federal law. incapacity and dependency within 60 days after you Your Group is required to inform the Subscriber of the receive our request, but not more frequently than date your membership becomes effective. For example, annually if the hire date of an otherwise-eligible employee is January 19, the waiting period begins on January 19 and Persons barred from enrolling the effective date of coverage cannot be any later than April 19. Note: Because the effective date of your You cannot enroll if you have had your entitlement to Group's coverage is always on the first day of the month, receive Services through Health Plan terminated for in this example the effective date cannot be any later cause. than April 1. Medicare late enrollment penalties Open enrollment If you become eligible for Medicare Part B and do not You may enroll as a Subscriber (along with any eligible enroll, Medicare may require you to pay a late Dependents), and existing Subscribers may add eligible enrollment penalty if you later enroll in Medicare Part B. Dependents, by submitting a Health Plan–approved However, if you delay enrollment in Part B because you enrollment application to your Group during your or your spouse are still working and have coverage Group's open enrollment period. Your Group will let you through an employer group health plan, you may not know when the open enrollment period begins and ends have to pay the penalty. Also, if you are (or become) and the effective date of coverage. eligible for Medicare and go without creditable prescription drug coverage (drug coverage that is at least as good as the standard Medicare Part D prescription Special enrollment drug coverage) for a continuous period of 63 days or If you do not enroll when you are first eligible and later more, you may have to pay a late enrollment penalty want to enroll, you can enroll only during open if you later sign up for Medicare prescription drug enrollment unless one of the following is true: coverage. If you are (or become) eligible for Medicare, • You become eligible as described in this "Special your Group is responsible for informing you about enrollment" section whether your drug coverage under this EOC is creditable • You did not enroll in any coverage offered by your prescription drug coverage at the times required by the Group when you were first eligible and your Group Centers for Medicare & Medicaid Services and upon does not give us a written statement that verifies you your request. signed a document that explained restrictions about enrolling in the future. The effective date of an When You Can Enroll and When enrollment resulting from this provision is no later than the first day of the month following the date Coverage Begins your Group receives a Health Plan–approved Your Group is required to inform you when you are enrollment or change of enrollment application from eligible to enroll and what your effective date of the Subscriber coverage is. If you are eligible to enroll as described under "Who Is Eligible" in this "Premiums, Eligibility, Special enrollment due to new Dependents. You may and Enrollment" section, enrollment is permitted as enroll as a Subscriber (along with eligible Dependents), described below and membership begins at the beginning and existing Subscribers may add eligible Dependents, (12:00 a.m.) of the effective date of coverage indicated within 60 days after marriage, establishment of domestic below, except that your Group may have additional partnership, birth, adoption, placement for adoption, or requirements, which allow enrollment in other situations. placement for foster care by submitting to your Group a Health Plan–approved enrollment application. New employees When your Group informs you that you are eligible to The effective date of an enrollment resulting from enroll as a Subscriber, you may enroll yourself and any marriage or establishment of domestic partnership is no later than the first day of the month following the date

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your Group receives an enrollment application from the submitting to your Group a Health Plan–approved Subscriber. Enrollments due to birth, adoption, enrollment or change of enrollment application. placement for adoption, or placement for foster care are effective on the date of birth, date of adoption, or the The effective date of coverage resulting from a court or date you or your Spouse have newly assumed a legal administrative order is the first of the month following right to control health care. the date we receive the enrollment request, unless your Group specifies a different effective date (if your Group Special enrollment due to loss of other coverage. You specifies a different effective date, the effective date may enroll as a Subscriber (along with any eligible cannot be earlier than the date of the order). Dependents), and existing Subscribers may add eligible Dependents, if all of the following are true: Special enrollment due to eligibility for premium • The Subscriber or at least one of the Dependents had assistance. You may enroll as a Subscriber (along with other coverage when he or she previously declined all eligible Dependents), and existing Subscribers may add coverage through your Group eligible Dependents, if you or a dependent become eligible for premium assistance through the Medi-Cal • The loss of the other coverage is due to one of the program. Premium assistance is when the Medi-Cal following: program pays all or part of premiums for employer group ♦ exhaustion of COBRA coverage coverage for a Medi-Cal beneficiary. To request ♦ termination of employer contributions for non- enrollment in your Group's health care coverage, the COBRA coverage Subscriber must submit a Health Plan–approved enrollment or change of enrollment application to your ♦ loss of eligibility for non-COBRA coverage, but Group within 60 days after you or a dependent become not termination for cause or termination from an eligible for premium assistance. Please contact the individual (nongroup) plan for nonpayment. For California Department of Health Care Services to find example, this loss of eligibility may be due to legal out if premium assistance is available and the eligibility separation or divorce, moving out of the plan's requirements. service area, reaching the age limit for dependent children, or the subscriber's death, termination of employment, or reduction in hours of employment Special enrollment due to reemployment after military service. If you terminated your health care ♦ loss of eligibility (but not termination for cause) coverage because you were called to active duty in the for coverage through Covered California, military service, you may be able to reenroll in your Medicaid coverage (known as Medi-Cal in Group's health plan if required by state or federal law. California), Children's Health Insurance Program Please ask your Group for more information. coverage, or Medi-Cal Access Program coverage ♦ reaching a lifetime maximum on all benefits Other special enrollment events. You may enroll as a Subscriber (along with any eligible Dependents) if you Note: If you are enrolling yourself as a Subscriber along or your Dependents were not previously enrolled, and with at least one eligible Dependent, only one of you existing Subscribers may add eligible Dependents not must meet the requirements stated above. previously enrolled, if any of the following are true: • You lose minimum essential coverage (for a reason To request enrollment, the Subscriber must submit a other than nonpayment of Premiums, termination for Health Plan–approved enrollment or change of cause, or rescission of coverage): enrollment application to your Group within 60 days after loss of other coverage. The effective date of an ♦ you lose your group health plan coverage (for enrollment resulting from loss of other coverage is no example, you lose eligibility as a subscriber later than the first day of the month following the date because you lose your job or your hours are your Group receives an enrollment or change of reduced, you lose eligibility as a dependent due to enrollment application from the Subscriber. legal separation, divorce, or reaching the age limit for dependent children, or you exhaust COBRA or Cal-COBRA coverage) Special enrollment due to court or administrative order. Within 60 days after the date of a court or ♦ you lose eligibility for individual plan coverage, administrative order requiring a Subscriber to provide Medicare, Medi-Cal, or other government- health care coverage for a Spouse or child who meets the sponsored health care program coverage eligibility requirements as a Dependent, the Subscriber • You become eligible for membership as a result of a may add the Spouse or child as a Dependent by permanent move

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• You were recently released from incarceration • Hospice care as described under "Hospice Care" in • You are an American Indian or Native Alaskan and the "Benefits and Your Cost Share" section Covered California determines that you are eligible • Visiting Member Services as described under for a monthly special enrollment period "Receiving Care Outside of your Home Region" in • Covered California determines that you are entitled to this "How to Obtain Services" section a special enrollment period (for example, Covered California determines that you didn't apply for As a Member, you are enrolled in one of two Health Plan coverage during the prior open enrollment because Regions in California (either our Northern California you were misinformed that you had minimum Region or Southern California Region), called your essential coverage) Home Region. The coverage information in this EOC applies when you obtain care in your Home Region. • You were under active care for certain conditions with a provider whose participation in your health Our medical care program gives you access to all of the plan ended (examples of conditions include: an acute covered Services you may need, such as routine care condition, a serious chronic condition, pregnancy, with your own personal Plan Physician, hospital care, terminal illness, care of newborn, or authorized laboratory and pharmacy Services, Emergency Services, nonelective surgeries) Urgent Care, and other benefits described in this EOC.

To request special enrollment, you must submit an application within 30 days after loss of other coverage. Routine Care You may be required to provide documentation that you have experienced a qualifying event. If you are If you need the following Services, you should schedule requesting enrollment in a plan offered through Covered an appointment: California, submit your application to Covered • Preventive Services California. If you are not requesting enrollment in a plan offered through Covered California, you must submit a • Periodic follow-up care (regularly scheduled follow- Health Plan-approved enrollment application to your up care, such as visits to monitor a chronic condition) Group. Membership becomes effective either on the first • Other care that is not Urgent Care day of the next month (for applications that are received by the fifteenth day of a month) or on the first day of the To make a non-urgent appointment, please refer to Your month following the next month (for applications that are Guidebook for appointment telephone numbers, or go to received after the fifteenth day of a month). our website at kp.org to request an appointment online.

Note: If you are enrolling as a Subscriber along with at least one eligible Dependent, only one of you must meet Urgent Care one of the requirements stated above. An Urgent Care need is one that requires prompt medical attention but is not an Emergency Medical Condition. If you think you may need Urgent Care, call the How to Obtain Services appropriate appointment or advice telephone number at a Plan Facility. Please refer to Your Guidebook or the As a Member, you are selecting our medical care facility directory on our website at kp.org for program to provide your health care. You must receive appointment and advice telephone numbers. all covered care from Plan Providers inside your Home Region Service Area, except as described in the sections For information about Out-of-Area Urgent Care, please listed below for the following Services: refer to "Urgent Care" in the "Emergency Services and • Authorized referrals as described under "Getting a Urgent Care" section. Referral" in this "How to Obtain Services" section • Emergency ambulance Services as described under "Ambulance Services" in the "Benefits and Your Cost Share" section • Emergency Services, Post-Stabilization Care, and Out-of-Area Urgent Care as described in the "Emergency Services and Urgent Care" section

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Not Sure What Kind of Care You Need? To learn how to select or change to a different personal Plan Physician, please refer to Your Guidebook, visit our Sometimes it's difficult to know what kind of care you website at kp.org, or call our Member Service Contact need, so we have licensed health care professionals Center. You can find a directory of our Plan Physicians available to assist you by phone 24 hours a day, seven on our website at kp.org. For the current list of days a week. Here are some of the ways they can help physicians that are available as Primary Care Physicians, you: please call the personal physician selection department at • They can answer questions about a health concern, the phone number listed in Your Guidebook. You can and instruct you on self-care at home if appropriate change your personal Plan Physician at any time for any reason. • They can advise you about whether you should get medical care, and how and where to get care (for example, if you are not sure whether your condition is Getting a Referral an Emergency Medical Condition, they can help you decide whether you need Emergency Services or Referrals to Plan Providers Urgent Care, and how and where to get that care) A Plan Physician must refer you before you can receive care from specialists, such as specialists in surgery, • They can tell you what to do if you need care and a orthopedics, cardiology, oncology, dermatology, and Plan Medical Office is closed or you are outside your physical, occupational, and speech therapies. Also, a Home Region Service Area Plan Physician must refer you before you can get care from Qualified Autism Service Providers covered under You can reach one of these licensed health care "Behavioral Health Treatment for Pervasive professionals by calling the appointment or advice Developmental Disorder or Autism" in the "Benefits and telephone number listed in Your Guidebook or the Your Cost Share" section. However, you do not need a facility directory on our website at kp.org. When you referral or prior authorization to receive most care from call, a trained support person may ask you questions to any of the following Plan Providers: help determine how to direct your call. • Your personal Plan Physician • Generalists in internal medicine, pediatrics, and Your Personal Plan Physician family practice Personal Plan Physicians provide primary care and play • Specialists in optometry, mental health Services, an important role in coordinating care, including hospital substance use disorder treatment, and stays and referrals to specialists. obstetrics/gynecology

We encourage you to choose a personal Plan Physician. A Plan Physician must refer you before you can get care You may choose any available personal Plan Physician. from a specialist in urology except that you do not need a Parents may choose a pediatrician as the personal Plan referral to receive Services related to sexual or Physician for their child. Most personal Plan Physicians reproductive health, such as a vasectomy. are Primary Care Physicians (generalists in internal medicine, pediatrics, or family practice, or specialists in Although a referral or prior authorization is not required obstetrics/gynecology whom the Medical Group to receive most care from these providers, a referral may designates as Primary Care Physicians). Some specialists be required in the following situations: who are not designated as Primary Care Physicians but • The provider may have to get prior authorization for who also provide primary care may be available as certain Services in accord with "Medical Group personal Plan Physicians. For example, some specialists authorization procedure for certain referrals" in this in internal medicine and obstetrics/gynecology who are "Getting a Referral" section not designated as Primary Care Physicians may be available as personal Plan Physicians. However, if you • The provider may have to refer you to a specialist choose a specialist who is not designated as a Primary who has a clinical background related to your illness Care Physician as your personal Plan Physician, the Cost or condition Share for a Physician Specialist Visit will apply to all visits with the specialist except for routine preventive Standing referrals visits listed under "Preventive Services" in the "Benefits If a Plan Physician refers you to a specialist, the referral and Your Cost Share" section. will be for a specific treatment plan. Your treatment plan may include a standing referral if ongoing care from the specialist is prescribed. For example, if you have a life-

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threatening, degenerative, or disabling condition, you can prescribed item is appropriate for your medical get a standing referral to a specialist if ongoing care from condition, the referral will be submitted to the Medical the specialist is required. Group's designee Plan Physician, who will make an authorization decision as described under "Medical Medical Group authorization procedure for Group's decision time frames" in this "Medical Group certain referrals authorization procedure for certain referrals" section. The following are examples of Services that require prior authorization by the Medical Group for the Services to Medical Group's decision time frames. The applicable be covered ("prior authorization" means that the Medical Medical Group designee will make the authorization Group must approve the Services in advance): decision within the time frame appropriate for your condition, but no later than five business days after • Durable medical equipment receiving all of the information (including additional • Ostomy and urological supplies examination and test results) reasonably necessary to • Services not available from Plan Providers make the decision, except that decisions about urgent Services will be made no later than 72 hours after receipt • Transplants of the information reasonably necessary to make the decision. If the Medical Group needs more time to make Utilization Management (UM) is a process that the decision because it doesn't have information determines whether a Service recommended by your reasonably necessary to make the decision, or because it treating provider is Medically Necessary for you. Prior has requested consultation by a particular specialist, you authorization is a UM process that determines whether and your treating physician will be informed about the the requested services are Medically Necessary before additional information, testing, or specialist that is care is provided. If it is Medically Necessary, then you needed, and the date that the Medical Group expects to will receive authorization to obtain that care in a make a decision. clinically appropriate place consistent with the terms of your health coverage. Decisions regarding requests for Your treating physician will be informed of the decision authorization will be made only by licensed physicians within 24 hours after the decision is made. If the Services or other appropriately licensed medical professionals. are authorized, your physician will be informed of the scope of the authorized Services. If the Medical Group For the complete list of Services that require prior does not authorize all of the Services, Health Plan will authorization, and the criteria that are used to make send you a written decision and explanation within two authorization decisions, please visit our website at business days after the decision is made. Any written kp.org/UM or call our Member Service Contact Center criteria that the Medical Group uses to make the decision to request a printed copy. Please refer to "Post- to authorize, modify, delay, or deny the request for Stabilization Care" under "Emergency Services" in the authorization will be made available to you upon request. "Emergency Services and Urgent Care" section for authorization requirements that apply to Post- If the Medical Group does not authorize all of the Stabilization Care from Non–Plan Providers. Services requested and you want to appeal the decision, you can file a grievance as described under "Grievances" Additional information about prior authorization for in the "Dispute Resolution" section. durable medical equipment and ostomy and urological supplies. The prior authorization process for Your Cost Share. For these referral Services, you pay durable medical equipment and ostomy and urological the Cost Share required for Services provided by a supplies includes the use of formulary guidelines. These Plan Provider as described in this EOC. guidelines were developed by a multidisciplinary clinical and operational work group with review and input from Travel and lodging for certain referrals Plan Physicians and medical professionals with clinical The following are examples of when we will arrange or expertise. The formulary guidelines are periodically provide reimbursement for certain travel and lodging updated to keep pace with changes in medical expenses in accord with our Travel and Lodging technology and clinical practice. Program Description: If your Plan Physician prescribes one of these items, he • If Medical Group refers you to a provider that is more or she will submit a written referral in accord with the than 50 miles from where you live for certain UM process described in this "Medical Group specialty Services such as bariatric surgery, complex authorization procedure for certain referrals" section. thoracic surgery, transplant nephrectomy, or inpatient If the formulary guidelines do not specify that the chemotherapy for leukemia and lymphoma

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• If Medical Group refers you to a provider that is ♦ it worsens over an extended period of time outside your Home Region Service Area for certain ♦ it requires ongoing treatment to maintain specialty Services such as a transplant or transgender remission or prevent deterioration surgery • Pregnancy and immediate postpartum care. We may cover these Services for the duration of the pregnancy For the complete list of specialty Services for which we and immediate postpartum care will arrange or provide reimbursement for travel and lodging expenses, the amount of reimbursement, • Terminal illnesses, which are incurable or irreversible limitations and exclusions, and how to request illnesses that have a high probability of causing death reimbursement, please refer to the Travel and Lodging within a year or less. We may cover completion of Program Description. The Travel and Lodging Program these Services for the duration of the illness Description is available online at kp.org/specialty- • Children under age 3. We may cover completion of care/travel-reimbursements or by calling our Member these Services until the earlier of (1) 12 months from Service Contact Center. the child's effective date of coverage if the child is a new Member, (2) 12 months from the termination Completion of Services from Non–Plan date of the terminated provider, or (3) the child's third Providers birthday New Member. If you are currently receiving Services • Surgery or another procedure that is documented as from a Non–Plan Provider in one of the cases listed part of a course of treatment and has been below under "Eligibility" and your prior plan's coverage recommended and documented by the provider to of the provider's Services has ended or will end when occur within 180 days of your effective date of your coverage with us becomes effective, you may be coverage if you are a new Member or within 180 days eligible for limited coverage of that Non–Plan Provider's of the termination date of the terminated provider Services. To qualify for this completion of Services coverage, all Terminated provider. If you are currently receiving of the following requirements must be met: covered Services in one of the cases listed below under "Eligibility" from a Plan Hospital or a Plan Physician (or • Your Health Plan coverage is in effect on the date certain other providers) when our contract with the you receive the Services provider ends (for reasons other than medical • For new Members, your prior plan's coverage of the disciplinary cause or criminal activity), you may be provider's Services has ended or will end when your eligible for limited coverage of that terminated provider's coverage with us becomes effective Services. • You are receiving Services in one of the cases listed Eligibility. The cases that are subject to this completion above from a Non–Plan Provider on your effective of Services provision are: date of coverage if you are a new Member, or from the terminated Plan Provider on the provider's • Acute conditions, which are medical conditions that termination date involve a sudden onset of symptoms due to an illness, • injury, or other medical problem that requires prompt For new Members, when you enrolled in Health Plan, medical attention and has a limited duration. We may you did not have the option to continue with your cover these Services until the acute condition ends previous health plan or to choose another plan (including an out-of-network option) that would • Serious chronic conditions until the earlier of (1) 12 cover the Services of your current Non–Plan Provider months from your effective date of coverage if you • are a new Member, (2) 12 months from the The provider agrees to our standard contractual terms termination date of the terminated provider, or (3) the and conditions, such as conditions pertaining to first day after a course of treatment is complete when payment and to providing Services inside your Home it would be safe to transfer your care to a Plan Region Service Area (the requirement that the Provider, as determined by Kaiser Permanente after provider agree to providing Services inside your consultation with the Member and Non–Plan Provider Home Region Service Area doesn't apply if you were and consistent with good professional practice. receiving covered Services from the provider outside Serious chronic conditions are illnesses or other the Service Area when the provider's contract medical conditions that are serious, if one of the terminated) following is true about the condition: • The Services to be provided to you would be covered ♦ it persists without full cure Services under this EOC if provided by a Plan Provider

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• You request completion of Services within 30 days second opinion is denied, you will be notified in writing (or as soon as reasonably possible) from your of the reasons for the denial and of your right to file a effective date of coverage if you are a new Member grievance as described under "Grievances" in the or from the termination date of the Plan Provider "Dispute Resolution" section.

Your Cost Share. For completion of Services, you pay Your Cost Share. For these referral Services, you pay the Cost Share required for Services provided by a the Cost Share required for Services provided by a Plan Provider as described in this EOC. Plan Provider as described in this EOC.

More information. For more information about this provision, or to request the Services or a copy of our Telehealth Visits "Completion of Covered Services" policy, please call our Telehealth Visits are intended to make it more Member Service Contact Center. convenient for you to receive covered Services, when a Plan Provider determines it is medically appropriate for Second Opinions your medical condition. You may receive covered Services via Telehealth Visits, when available and if the If you want a second opinion, you can ask Member Services would have been covered under this EOC Services to help you arrange one with a Plan Physician if provided in person. You are not required to use who is an appropriately qualified medical professional Telehealth Visits. for your condition. If there isn't a Plan Physician who is an appropriately qualified medical professional for your Your Cost Share. Please refer to "Outpatient Care" in condition, Member Services will help you arrange a the "Benefits and Your Cost Share" section for your Cost consultation with a Non–Plan Physician for a second Share for Telehealth Visits. opinion. For purposes of this "Second Opinions" provision, an "appropriately qualified medical professional" is a physician who is acting within his or Contracts with Plan Providers her scope of practice and who possesses a clinical How Plan Providers are paid background, including training and expertise, related to the illness or condition associated with the request for a Health Plan and Plan Providers are independent second medical opinion. contractors. Plan Providers are paid in a number of ways, such as salary, capitation, per diem rates, case rates, fee for service, and incentive payments. To learn more about Here are some examples of when a second opinion may how Plan Physicians are paid to provide or arrange be provided or authorized: medical and hospital care for Members, please visit our • Your Plan Physician has recommended a procedure website at kp.org or call our Member Service Contact and you are unsure about whether the procedure is Center. reasonable or necessary • You question a diagnosis or plan of care for a Financial liability condition that threatens substantial impairment or loss Our contracts with Plan Providers provide that you are of life, limb, or bodily functions not liable for any amounts we owe. However, you may have to pay the full price of noncovered Services you • The clinical indications are not clear or are complex obtain from Plan Providers or Non–Plan Providers. and confusing • A diagnosis is in doubt due to conflicting test results Your Cost Share. When you are referred to a Plan • The Plan Physician is unable to diagnose the Provider for covered Services, you pay the Cost Share condition required for Services from that provider as described in this EOC. • The treatment plan in progress is not improving your medical condition within an appropriate period of Termination of a Plan Provider's contract time, given the diagnosis and plan of care If our contract with any Plan Provider terminates while • You have concerns about the diagnosis or plan of care you are under the care of that provider, we will retain financial responsibility for the covered Services you An authorization or denial of your request for a second receive from that provider until we make arrangements opinion will be provided in an expeditious manner, as for the Services to be provided by another Plan Provider appropriate for your condition. If your request for a and notify you of the arrangements. You may be eligible

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to receive Services from a terminated provider; please Receiving care outside of any Region refer to "Completion of Services from Non–Plan If you are outside of a Kaiser Permanente Region, we Providers" under "Getting a Referral" in this "How to cover Emergency Services and Urgent Care as described Obtain Services" section. in the "Emergency Services and Urgent Care" section.

Provider groups and hospitals. If you are assigned to a provider group or hospital whose contract with us Your ID Card terminates, or if you live within 15 miles of a hospital whose contract with us terminates, we will give you Each Member's Kaiser Permanente ID card has a medical written notice at least 60 days before the termination (or record number on it, which you will need when you call as soon as reasonably possible). for advice, make an appointment, or go to a provider for covered care. When you get care, please bring your Kaiser Permanente ID card and a photo ID. Your Receiving Care Outside of your Home medical record number is used to identify your medical Region records and membership information. Your medical record number should never change. Please call our If you have questions about your coverage when you are Member Service Contact Center if we ever inadvertently away from home, call the Away from Home Travel line issue you more than one medical record number or if you at 951-268-3900 24 hours a day, seven days a week need to replace your Kaiser Permanente ID card. (except closed holidays). For example, call this number for the following concerns: Your ID card is for identification only. To receive covered Services, you must be a current Member. • What you should do to prepare for your trip Anyone who is not a Member will be billed as a non- • What Services are covered when you are outside our Member for any Services he or she receives. If you let Service Area someone else use your ID card, we may keep your ID • How to get care in another Region card and terminate your membership as described under "Termination for Cause" in the "Termination of • How to request reimbursement if you paid for Membership" section. covered Services outside our Service Area

You can also get information on our website at Timely Access to Care kp.org/travel. Standards for appointment availability Receiving Care in the Service Area of another The California Department of Managed Health Care Region ("DMHC") developed the following standards for appointment availability. This information can help you If you are visiting in the service area of another Region, know what to expect when you request an appointment. you may receive Visiting Member Services from designated providers in that Region. "Visiting Member • Urgent Care: within 48 hours Services" are Services that are covered under your Home • Nonurgent Primary Care Visit or Non-Physician Region plan that you receive in another Region, subject Specialist Visit: within 10 business days to exclusions, limitations, prior authorization or approval requirements, and reductions described in this EOC or • Physician Specialist Visit: within 15 business days the Visiting Member Brochure, which is available online at kp.org. Certain Services are not covered as Visiting If you prefer to wait for a later appointment that will Member Services. For more information about receiving better fit your schedule or to see the Plan Provider of Visiting Member Services in another Region, including your choice, we will respect your preference. In some provider and facility locations, or to obtain a copy of the cases, your wait may be longer than the time listed if a Visiting Member Brochure, please call our Away from licensed health care professional decides that a later Home Travel Line at 951-268-3900 24 hours a day, appointment won't have a negative effect on your health. seven days a week (except closed holidays). Information is also available online at kp.org/travel. The standards for appointment availability do not apply to Preventive Services. Your Plan Provider may Your Cost Share. For Visiting Member Services, you recommend a specific schedule for Preventive Services, pay the Cost Share required for Services provided by depending on your needs. The standards also do not a Plan Provider inside your Home Region Service apply to periodic follow-up care for ongoing conditions Area as described in this EOC. or standing referrals to specialists.

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Timely access to telephone assistance facility directory on our website at kp.org for DMHC developed the following standards for answering addresses) telephone questions: Website kp.org • For telephone advice about whether you need to get care and where to get care: within 30 minutes, 24 Cost Share estimates hours a day, 7 days a week. For information about estimates, see "Getting an estimate • For general questions: within 10 minutes during of your Cost Share" under "Your Cost Share" in the normal business hours. "Benefits and Your Cost Share" section.

Interpreter services If you need interpreter services when you call us or when Plan Facilities you get covered Services, please let us know. Interpreter services, including sign language, are available during all Plan Medical Offices and Plan Hospitals for your area business hours at no cost to you. For more information are listed in Your Guidebook to Kaiser Permanente on the interpreter services we offer, please call our Services (Your Guidebook) and on our website at kp.org. Member Service Contact Center. Your Guidebook describes the types of covered Services that are available from each Plan Facility in your area, because some facilities provide only specific types of Getting Assistance covered Services. Also, it explains how to use our We want you to be satisfied with the health care you Services and make appointments, lists hours of receive from Kaiser Permanente. If you have any operation, and includes a detailed telephone directory for questions or concerns, please discuss them with your appointments and advice. If you have any questions personal Plan Physician or with other Plan Providers about the current locations of Plan Medical Offices who are treating you. They are committed to your and/or Plan Hospitals, please call our Member Service satisfaction and want to help you with your questions. Contact Center.

Member Services At most of our Plan Facilities, you can usually receive all of the covered Services you need, including specialty Member Services representatives can answer any care, pharmacy, and lab work. You are not restricted to a questions you have about your benefits, available particular Plan Facility, and we encourage you to use the Services, and the facilities where you can receive care. facility that will be most convenient for you: For example, they can explain the following: • All Plan Hospitals provide inpatient Services and are • Your Health Plan benefits open 24 hours a day, seven days a week • How to make your first medical appointment • Emergency Services are available from Plan Hospital • What to do if you move Emergency Departments as described in Your • How to replace your ID card Guidebook (please refer to Your Guidebook or the facility directory on our website at kp.org for You can reach Member Services in the following ways: Emergency Department locations in your area) • Call 1-800-464-4000 (English and more than 150 Same–day Urgent Care appointments are available at languages using interpreter services) many locations (please refer to Your Guidebook or 1-800-788-0616 (Spanish) the facility directory on our website at kp.org for 1-800-757-7585 (Chinese dialects) Urgent Care locations in your area) TTY users call 711 • Many Plan Medical Offices have evening and weekend appointments 24 hours a day, seven days a week (except closed holidays) • Many Plan Facilities have a Member Services Department (refer to Your Guidebook or the facility Member Services Department at a Plan Visit directory on our website at kp.org for locations in Facility (refer to Your Guidebook or the your area) facility directory on our website at kp.org for addresses) Write Member Services Department at a Plan Facility (refer to Your Guidebook or the

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Note: State law requires evidence of coverage documents applicable law ("prior authorization" means that we must to include the following notice: approve the Services in advance).

Some hospitals and other providers do not To request prior authorization, the provider must call provide one or more of the following services 1-800-225-8883 or the notification telephone number on that may be covered under your plan your Kaiser Permanente ID card before you receive the contract and that you or your family care. We will discuss your condition with the Non–Plan member might need: family planning; Provider. If we determine that you require Post- Stabilization Care and that this care is part of your contraceptive services, including emergency covered benefits, we will authorize your care from the contraception; sterilization, including tubal Non–Plan Provider or arrange to have a Plan Provider (or ligation at the time of labor and delivery; other designated provider) provide the care. If we decide infertility treatments; or abortion. You to have a Plan Hospital, Plan Skilled Nursing Facility, or should obtain more information before you designated Non–Plan Provider provide your care, we may authorize special transportation services that are enroll. Call your prospective doctor, medical medically required to get you to the provider. This may group, independent practice association, or include transportation that is otherwise not covered. clinic, or call the Kaiser Permanente Member Service Contact Center, to ensure Be sure to ask the Non–Plan Provider to tell you what that you can obtain the health care services care (including any transportation) we have authorized that you need. because we will not cover unauthorized Post- Stabilization Care or related transportation provided by Non–Plan Providers. If you receive care from a Non– Please be aware that if a Service is covered but not Plan Provider that we have not authorized, you may have available at a particular Plan Facility, we will make it to pay the full cost of that care. If you are admitted to a available to you at another facility. Non–Plan Hospital, please notify us as soon as possible by calling 1-800-225-8883 or the notification telephone number on your Kaiser Permanente ID card. Emergency Services and Urgent Your Cost Share Care Your Cost Share for covered Emergency Services and Post-Stabilization Care is described in the "Benefits and Emergency Services Your Cost Share" section. Your Cost Share is the same whether you receive the Services from a Plan Provider or If you have an Emergency Medical Condition, call 911 a Non–Plan Provider. For example: (where available) or go to the nearest hospital • If you receive Emergency Services in the Emergency Emergency Department. You do not need prior Department of a Non–Plan Hospital, you pay the Cost authorization for Emergency Services. When you have Share for an Emergency Department visit as an Emergency Medical Condition, we cover Emergency described under "Outpatient Care" Services you receive from Plan Providers or Non–Plan Providers anywhere in the world. • If we gave prior authorization for inpatient Post- Stabilization Care in a Non–Plan Hospital, you pay Emergency Services are available from Plan Hospital the Cost Share for hospital inpatient care as described Emergency Departments 24 hours a day, seven days a under "Hospital Inpatient Care" week. Urgent Care Post-Stabilization Care Post-Stabilization Care is Medically Necessary Services Inside the Service Area related to your Emergency Medical Condition that you An Urgent Care need is one that requires prompt medical receive in a hospital (including the Emergency attention but is not an Emergency Medical Condition. Department) after your treating physician determines that If you think you may need Urgent Care, call the this condition is Stabilized. We cover Post-Stabilization appropriate appointment or advice telephone number at a Care from a Non–Plan Provider only if we provide prior Plan Facility. Please refer to Your Guidebook for authorization for the care or if otherwise required by appointment and advice telephone numbers.

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Out-of-Area Urgent Care and Your Cost Share" section, you are not responsible If you need Urgent Care due to an unforeseen illness, for any amounts beyond your Cost Share for covered unforeseen injury, or unforeseen complication of an Emergency Services. However, if the provider does not existing condition (including pregnancy), we cover agree to bill us, you may have to pay for the Services and Medically Necessary Services to prevent serious file a claim for reimbursement. Also, you may be deterioration of your (or your unborn child's) health from required to pay and file a claim for any Services a Non–Plan Provider if all of the following are true: prescribed by a Non–Plan Provider as part of covered Emergency Services, Post-Stabilization Care, and Out- • You receive the Services from Non–Plan Providers of-Area Urgent Care even if you receive the Services while you are temporarily outside your Home Region from a Plan Provider, such as a Plan Pharmacy. Service Area • A reasonable person would have believed that your For information on how to file a claim, please see the (or your unborn child's) health would seriously "Post-Service Claims and Appeals" section. deteriorate if you delayed treatment until you returned to your Home Region Service Area

You do not need prior authorization for Out-of-Area Benefits and Your Cost Share Urgent Care. We cover Out-of-Area Urgent Care you receive from Non–Plan Providers if the Services would We cover the Services described in this "Benefits and have been covered under this EOC if you had received Your Cost Share" section, subject to the "Exclusions, them from Plan Providers. Limitations, Coordination of Benefits, and Reductions" section, only if all of the following conditions are We do not cover follow-up care from Non–Plan satisfied: Providers after you no longer need Urgent Care. To • You are a Member on the date that you receive the obtain follow-up care from a Plan Provider, call the Services appointment or advice telephone number listed in Your • The Services are Medically Necessary Guidebook. • The Services are one of the following: Your Cost Share ♦ Preventive Services Your Cost Share for covered Urgent Care is the Cost ♦ health care items and services for diagnosis, Share required for Services provided by Plan Providers assessment, or treatment as described in this EOC. For example: ♦ health education covered under "Health • If you receive an Urgent Care evaluation as part of Education" in this "Benefits and Your Cost Share" covered Out-of-Area Urgent Care from a Non–Plan section Provider, you pay the Cost Share for Urgent Care ♦ other health care items and services consultations, evaluations, and treatment as described ♦ under "Outpatient Care" other services to treat Severe Mental Illness and Serious Emotional Disturbance of a Child Under • If the Out-of-Area Urgent Care you receive includes Age 18 an X-ray, you pay the Cost Share for an X-ray as • described under "Outpatient Imaging, Laboratory, and The Services are provided, prescribed, authorized, or Special Procedures" in addition to the Cost Share for directed by a Plan Physician except where the Urgent Care evaluation specifically noted to the contrary in the sections listed below for the following Services: Note: If you receive Urgent Care in an Emergency ♦ drugs prescribed by dentists as described under Department, you pay the Cost Share for an Emergency "Outpatient Prescription Drugs, Supplies, and Department visit as described under "Outpatient Care." Supplements" in this "Benefits and Your Cost Share" section ♦ emergency ambulance Services as described under Payment and Reimbursement "Ambulance Services" in this "Benefits and Your Cost Share" section If you receive Emergency Services, Post-Stabilization Care, or Out-of-Area Urgent Care from a Non–Plan ♦ Emergency Services, Post-Stabilization Care, and Provider as described in this "Emergency Services and Out-of-Area Urgent Care as described in the Urgent Care" section, or emergency ambulance Services "Emergency Services and Urgent Care" section described under "Ambulance Services" in the "Benefits

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♦ eyeglasses and contact lenses prescribed by Non– Your Cost Share Plan Providers as described under "Vision Services for Adult Members" and "Vision Services Your Cost Share is the amount you are required to pay for Pediatric Members" in this "Benefits and Your for covered Services. The Cost Share for covered Cost Share" section Services is listed in this EOC. For example, your Cost ♦ Visiting Member Services as described under Share may be a Copayment or Coinsurance. If your "Receiving Care Outside of your Home Region" in coverage includes a Plan Deductible and you receive the "How to Obtain Services" section Services that are subject to the Plan Deductible, your Cost Share for those Services will be Charges until you • You receive the Services from Plan Providers inside reach the Plan Deductible. Similarly, if your coverage your Home Region Service Area, except where includes a Drug Deductible, and you receive Services specifically noted to the contrary in the sections listed that are subject to the Drug Deductible, your Cost Share below for the following Services: for those Services will be Charges until you reach the ♦ authorized referrals as described under "Getting a Drug Deductible. Referral" in the "How to Obtain Services" section ♦ emergency ambulance Services as described under General rules, examples, and exceptions "Ambulance Services" in this "Benefits and Your Your Cost Share for covered Services will be the Cost Cost Share" section Share in effect on the date you receive the Services, ♦ Emergency Services, Post-Stabilization Care, and except as follows: Out-of-Area Urgent Care as described in the • If you are receiving covered inpatient hospital or "Emergency Services and Urgent Care" section Skilled Nursing Facility Services on the effective date ♦ hospice care as described under "Hospice Care" in of this EOC, you pay the Cost Share in effect on your this "Benefits and Your Cost Share" section admission date until you are discharged if the Services were covered under your prior Health Plan ♦ Visiting Member Services as described under "Receiving Care Outside of your Home Region" in evidence of coverage and there has been no break in the "How to Obtain Services" section coverage. However, if the Services were not covered under your prior Health Plan evidence of coverage, or • The Medical Group has given prior authorization for if there has been a break in coverage, you pay the the Services if required under "Medical Group Cost Share in effect on the date you receive the authorization procedure for certain referrals" in the Services "How to Obtain Services" section • For items ordered in advance, you pay the Cost Share in effect on the order date (although we will not cover The only Services we cover under this EOC are those the item unless you still have coverage for it on the that this EOC says that we cover, subject to exclusions date you receive it) and you may be required to pay and limitations described in this EOC and to all the Cost Share when the item is ordered. For provisions in the "Exclusions, Limitations, Coordination outpatient prescription drugs, the order date is the of Benefits, and Reductions" section. The "Exclusions, date that the pharmacy processes the order after Limitations, Coordination of Benefits, and Reductions" receiving all of the information they need to fill the section describes exclusions, limitations, reductions, and prescription coordination of benefits provisions that apply to all Services that would otherwise be covered. When an exclusion or limitation applies only to a particular Cost Share for Services received by newborn children benefit, it is listed in the description of that benefit in this of a Member. During the 31 days of automatic coverage EOC. Also, please refer to: for newborn children described under "Newborn coverage" under "Who Is Eligible" in the "Premiums, • The "Emergency Services and Urgent Care" section Eligibility, and Enrollment" section, the parent or for information about how to obtain covered guardian of the newborn must pay the Cost Share Emergency Services, Post-Stabilization Care, and indicated in this "Benefits and Your Cost Share" section Out-of-Area Urgent Care for any Services that the newborn receives, whether or • Your Guidebook or the facility directory on our not the newborn is enrolled. When the Cost Share for the website at kp.org for the types of covered Services Services is described as "subject to the Plan Deductible," that are available from each Plan Facility in your the Cost Share for those Services will be Charges if the area, because some facilities provide only specific newborn has not met the Plan Deductible. types of covered Services Payment toward your Cost Share (and when you may be billed). In most cases, your provider will ask you to

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make a payment toward your Cost Share at the time you In some cases, your provider will not ask you to make a receive Services. If you receive more than one type of payment at the time you receive Services, and you will Services (such as a routine physical maintenance exam be billed for your Cost Share. The following are and laboratory tests), you may be required to pay examples of when you will be billed: separate Cost Shares for each of those Services. Keep in • A Plan Provider is not able to collect Cost Share at mind that your payment toward your Cost Share may the time you receive Services (for example, some cover only a portion of your total Cost Share for the Laboratory Departments are not able to collect Cost Services you receive, and you will be billed for any Shares, or your Plan Provider is not able to collect additional amounts that are due. The following are Cost Share, if any, for Telehealth Visits you receive examples of when you may be asked to pay (or you may at home) be billed for) Cost Share amounts in addition to the amount you pay at check-in: • You ask to be billed for some or all of your Cost Share • You receive non-preventive Services during a preventive visit. For example, you go in for a routine • Medical Group authorizes a referral to a Non–Plan physical maintenance exam, and at check-in you pay Provider and that provider does not collect your Cost your Cost Share for the preventive exam (your Cost Share at the time you receive Services Share may be "no charge"). However, during your • You receive covered Emergency Services or Out-of- preventive exam your provider finds a problem with Area Urgent Care from a Non–Plan Provider and that your health and orders non-preventive Services to provider does not collect your Cost Share at the time diagnose your problem (such as laboratory tests). You you receive Services may be asked to pay (or you will be billed for) your Cost Share for these additional non-preventive When we send you a bill, it will list Charges for the diagnostic Services Services you received, payments and credits applied to • You receive diagnostic Services during a treatment your account, and any amounts you still owe. Your visit. For example, you go in for treatment of an current bill may not always reflect your most recent existing health condition, and at check-in you pay Charges and payments. Any Charges and payments that your Cost Share for a treatment visit. However, are not on the current bill will appear on a future bill. during the visit your provider finds a new problem Sometimes, you may see a payment but not the related with your health and performs or orders diagnostic Charges for Services. That could be because your Services (such as laboratory tests). You may be asked payment was recorded before the Charges for the to pay (or you will be billed for) your Cost Share for Services were processed. If so, the Charges will appear these additional diagnostic Services on a future bill. Also, you may receive more than one bill for a single outpatient visit or inpatient stay. For • You receive treatment Services during a diagnostic example, you may receive a bill for physician services visit. For example, you go in for a diagnostic exam, and a separate bill for hospital services. If you don't see and at check-in you pay your Cost Share for a all the Charges for Services on one bill, they will appear diagnostic exam. However, during the diagnostic on a future bill. If we determine that you overpaid and exam your provider confirms a problem with your are due a refund, then we will send a refund to you health and performs treatment Services (such as an within 4 weeks after we make that determination. If you outpatient procedure). You may be asked to pay (or have questions about a bill, please call the phone number you will be billed for) your Cost Share for these on the bill. additional treatment Services • You receive Services from a second provider during In some cases, a Non–Plan Provider may be involved in your visit. For example, you go in for a diagnostic the provision of covered Services at a Plan Facility or a exam, and at check-in you pay your Cost Share for a contracted facility where we have authorized you to diagnostic exam. However, during the diagnostic receive care. You are not responsible for any amounts exam your provider requests a consultation with a beyond your Cost Share for the covered Services you specialist. You may be asked to pay (or you will be receive at Plan Facilities or at contracted facilities where billed for) your Cost Share for the consultation with we have authorized you to receive care. However, if the the specialist provider does not agree to bill us, you may have to pay for the Services and file a claim for reimbursement. For information on how to file a claim, please see the "Post- Service Claims and Appeals" section.

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Primary Care Visits, Non-Physician Specialist Visits, since not everything about your care can be known in and Physician Specialist Visits. The Cost Share for a advance. Primary Care Visit applies to evaluations and treatment provided by generalists in internal medicine, pediatrics, Explanation of benefits or family practice, and by specialists in After you receive Services, we will send you an obstetrics/gynecology whom the Medical Group explanation of benefits statement. The explanation of designates as Primary Care Physicians. Some physician benefits is not a bill. It shows your total accumulation specialists provide primary care in addition to specialty toward the Plan Deductible and Plan Out-of-Pocket care but are not designated as Primary Care Physicians. Maximum. You can also view a copy of your If you receive Services from one of these specialists, the explanation of benefits on kp.org or you may request a Cost Share for a Physician Specialist Visit will apply to copy by calling our Member Service Contact Center at all consultations, evaluations, and treatment provided by 1-800-390-3507 (TTY users call 711) Monday through the specialist except for routine preventive counseling Friday 7 a.m. to 7 p.m. and exams listed under "Preventive Services" in this "Benefits and Your Cost Share" section. For example, Drug Deductible if your personal Plan Physician is a specialist in internal Please refer to "Outpatient Prescription Drugs, Supplies, medicine or obstetrics/gynecology who is not a Primary and Supplements" in this "Benefits and Your Cost Share" Care Physician, you will pay the Cost Share for a section for Services that are subject to the Drug Physician Specialist Visit for all consultations, Deductible and the Drug Deductible amount. When the evaluations, and treatment by the specialist except Cost Share for the Services is described as "subject to the routine preventive counseling and exams listed under Drug Deductible," your Cost Share for those Services "Preventive Services" in this "Benefits and Your Cost will be Charges until you reach the Drug Deductible. Share" section. The Non-Physician Specialist Visit Cost Note: When the Cost Share for the Services is described Share applies to consultations, evaluations, and treatment as "no charge subject to the Drug Deductible," your Cost provided by non-physician specialists (such as nurse Share for those Services will be Charges until you reach practitioners, physician assistants, optometrists, the Drug Deductible. podiatrists, and audiologists). Plan Deductible Noncovered Services. If you receive Services that are In any Accumulation Period, you must pay Charges for not covered under this EOC, you may have to pay the Services subject to the Plan Deductible until you reach full price of those Services. Payments you make for one of the following Plan Deductible amounts: noncovered Services do not apply to any deductible or out-of-pocket maximum. Self-only coverage (a Family of one Member): Getting an estimate of your Cost Share • $1,000 per Accumulation Period If you have questions about the Cost Share for specific Services that you expect to receive or that your provider Family coverage (a Family of two or more Members): orders during a visit or procedure, please visit our • $1,000 per Accumulation Period for each Member in website at kp.org/memberestimates to use our cost the Family estimate tool or call our Member Service Contact Center. • $2,000 per Accumulation Period for the entire • If you have a Plan Deductible and would like an Family estimate for Services that are subject to the Plan Deductible, please call 1-800-390-3507 (TTY users If you are a Member in a Family of two or more call 711) Monday through Friday 7 a.m. to 7 p.m. Members, you reach the Plan Deductible either when you Refer to "Plan Deductible" under "Your Cost Share" reach the amount for any one Member, or when your in the "Benefits and Your Cost Share" section of this entire Family reaches the Family amount. For example, EOC to find out if you have a Plan Deductible suppose you have reached the $1,000 amount for any one • For all other Cost Share estimates, please call Member. For Services subject to the Plan Deductible, 1-800-464-4000 (TTY users call 711) 24 hours a day, you will not pay Charges during the remainder of the seven days a week (except closed holidays) Accumulation Period, but every other Member in your Family must continue to pay Charges during the Cost Share estimates are based on your benefits and the remainder of the Accumulation Period until either he or Services you expect to receive. They are a prediction of she reaches the $1,000 amount for any one Member, or cost and not a guarantee of the final cost of Services. the entire Family reaches the $2,000 Family amount. Your final cost may be higher or lower than the estimate

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After you reach the Plan Deductible and for the Family coverage (a Family of two or more Members): remainder of the Accumulation Period, you pay the • $7,000 per Accumulation Period for each Member in applicable Copayment or Coinsurance subject to the the Family limits described under "Plan Out-of-Pocket Maximum" in this "Benefits and Your Cost Share" section. • $14,000 per Accumulation Period for the entire Family Services that are subject to the Plan Deductible. The Cost Share that you must pay for covered Services is If you are a Member in a Family of two or more described in this EOC. When the Cost Share for the Members, you reach the Plan Out-of-Pocket Maximum Services is described as "subject to the Plan Deductible," either when you reach the maximum for any one your Cost Share for those Services will be Charges until Member, or when your Family reaches the Family you reach the Plan Deductible. Note: When the Cost maximum. For example, suppose you have reached the Share for the Services is described as "no charge subject $7,000 maximum for any one Member. For Services to the Plan Deductible," your Cost Share for those subject to the Plan Out-of-Pocket Maximum, you will Services will be Charges until you reach the Plan not pay any more Cost Share during the remainder of the Deductible. Also, if you pay a Plan Deductible amount Accumulation Period, but every other Member in your for a Service that has a limit, such as a visit limit, the Family must continue to pay Cost Share during the Services count toward reaching the limit. remainder of the Accumulation Period until either he or she reaches the $7,000 maximum for any one Member or The only payments that count toward the Plan your Family reaches the $14,000 Family maximum. Deductible are those you make for covered Services that are subject to this Plan Deductible under this EOC. Payments that count toward the Plan Out-of-Pocket Maximum. Any payments you make toward the Plan Keeping track of the Plan Deductible. When you pay Deductible or Drug Deductible, if applicable, apply an amount toward your Plan Deductible, we will give toward the maximum. you a receipt that shows how much you paid. To see how close you are to reaching your Plan Deductible, use our Also, Copayments and Coinsurance you pay for covered online Out-of-Pocket Summary tool at Services apply to the maximum, except as described kp.org/outofpocket, refer to your summary or below: explanation of benefits, or call our Member Service • If your plan includes supplemental chiropractic or Contact Center. acupuncture Services described in an Amendment to this EOC, those Services do not apply toward the Copayments and Coinsurance maximum The Copayment or Coinsurance you must pay for each • If your plan includes an Allowance for specific covered Service, after you meet any applicable Services (such as eyeglasses, contact lenses, or deductible, is described in this EOC. hearing aids), any amounts you pay that exceed the Allowance do not apply toward the maximum Note: If Charges for Services are less than the Copayment described in this EOC, you will pay the If your plan includes pediatric dental Services described lesser amount. in a Pediatric Dental Services Amendment to this EOC, those Services will apply toward the maximum. If your Plan Out-of-Pocket Maximum plan has a Pediatric Dental Services Amendment, it will There is a limit to the total amount of Cost Share you be attached to this EOC, and it will be listed in the EOC's must pay under this EOC in the Accumulation Period for Table of Contents. covered Services that you receive in the same Accumulation Period. The Services that apply to the Plan Keeping track of the Plan Out-of-Pocket Maximum. Out-of-Pocket Maximum are described under the When you receive Services, we will give you a receipt "Payments that count toward the Plan Out-of-Pocket that shows how much you paid. To see how close you Maximum" section below. The limit is one of the are to reaching your Plan Out-of-Pocket Maximum, use following amounts: our online Out-of-Pocket Summary tool at kp.org/outofpocket or call our Member Service Contact Self-only coverage (a Family of one Member): Center. • $7,000 per Accumulation Period

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Outpatient Care • Scheduled telephone visits: ♦ Primary Care Visits and Non-Physician Specialist We cover the following outpatient care subject to the Visits: no charge (not subject to the Plan Cost Share indicated: Deductible) ♦ Physician Specialist Visits: no charge (not Office visits subject to the Plan Deductible) • Primary Care Visits and Non-Physician Specialist Visits that are not described elsewhere in this EOC: a Emergency and Urgent Care visits $50 Copayment per visit (not subject to the Plan • Emergency Department visits: Deductible) 35% Coinsurance subject to the Plan Deductible. If you are admitted • Physician Specialist Visits that are not described to the hospital as an inpatient for covered Services elsewhere in this EOC: a $70 Copayment per visit (either directly or after an observation stay), then the (not subject to the Plan Deductible) Services you received in the Emergency Department • Outpatient visits that are available as group and observation stay, if applicable, will be considered appointments that are not described elsewhere in this part of your inpatient hospital stay. For the Cost EOC: a $25 Copayment per visit (not subject to the Share for inpatient care, please refer to "Hospital Plan Deductible) Inpatient Care" in this "Benefits and Your Cost Share" section. However, the Emergency Department • House calls by a Plan Physician (or a Plan Provider Cost Share does apply if you are admitted for who is a registered nurse) inside your Home Region observation but are not admitted as an inpatient Service Area when care can best be provided in your home as determined by a Plan Physician: no charge • Urgent Care consultations, evaluations, and (not subject to the Plan Deductible) treatment: a $50 Copayment per visit (not subject to the Plan Deductible) • Acupuncture Services (typically provided only for the treatment of nausea or as part of a comprehensive Outpatient surgeries and procedures pain management program for the treatment of chronic pain): • Outpatient surgery and outpatient procedures when ♦ Non-Physician Specialist Visits: a provided in an outpatient or ambulatory surgery $50 Copayment per visit (not subject to the center or in a hospital operating room, or if it is Plan Deductible) provided in any setting and a licensed staff member monitors your vital signs as you regain sensation after ♦ Physician Specialist Visits: a $70 Copayment per receiving drugs to reduce sensation or to minimize visit (not subject to the Plan Deductible) discomfort: 35% Coinsurance subject to the Plan • Allergy testing and treatment Deductible ♦ consultations for allergy conditions and allergy • Any other outpatient surgery that does not require a testing: a $70 Copayment per visit (not subject licensed staff member to monitor your vital signs as to the Plan Deductible) described above: a $70 Copayment per procedure ♦ allergy injections (including allergy serum): a (not subject to the Plan Deductible) $5 Copayment per visit (not subject to the Plan • Any other outpatient procedures that do not require a Deductible) licensed staff member to monitor your vital signs as described above: the Cost Share that would Telehealth Visits otherwise apply for the procedure in this "Benefits Services described under "Telehealth Visits" in the "How and Your Cost Share" section (for example, radiology to Obtain Services" section: procedures that do not require a licensed staff • Interactive video visits: member to monitor your vital signs as described above are covered under "Outpatient Imaging, ♦ Primary Care Visits and Non-Physician Specialist Laboratory, and Special Procedures") Visits: no charge (not subject to the Plan Deductible) Administered drugs and products ♦ Physician Specialist Visits: no charge (not Administered drugs and products are medications and subject to the Plan Deductible) products that require administration or observation by medical personnel. We cover these items when prescribed by a Plan Provider, in accord with our drug

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formulary guidelines, and they are administered to you in • Outpatient Prescription Drugs, Supplies, and a Plan Facility or during home visits. Supplements • Preventive Services Certain administered drugs are Preventive Services. Please refer to "Family Planning Services" for • Prosthetic and Orthotic Devices information about administered contraceptives and refer • Reconstructive Surgery to "Preventive Services" for information on • Rehabilitative and Habilitative Services immunizations. • Services in Connection with a Clinical Trial We cover the following Services and their administration • Substance Use Disorder Treatment in a Plan Facility at the Cost Share indicated: • Transplant Services • Blood and blood products: no charge (not subject to • the Plan Deductible) Vision Services for Adult Members • • Cancer chemotherapy drugs and adjuncts: no charge Vision Services for Pediatric Members (not subject to the Plan Deductible) • Drugs and products that are administered via Hospital Inpatient Care intravenous therapy or injection that are not for cancer chemotherapy: no charge (not subject to the We cover the following inpatient Services in a Plan Plan Deductible) Hospital, when the Services are generally and customarily provided by acute care general hospitals • All other administered drugs: no charge (not subject inside your Home Region Service Area: to the Plan Deductible) • Room and board, including a private room We cover drugs and products administered to you during if Medically Necessary a home visit at no charge (not subject to the Plan • Specialized care and critical care units Deductible). • General and special nursing care Coverage for Services related to "Outpatient • Operating and recovery rooms Care" described in other sections • Services of Plan Physicians, including consultation The following types of outpatient Services are covered and treatment by specialists only as described under these headings in this "Benefits • Anesthesia and Your Cost Share" section: • Drugs prescribed in accord with our drug formulary • Bariatric Surgery guidelines (for discharge drugs prescribed when you • Behavioral Health Treatment for Pervasive are released from the hospital, please refer to Developmental Disorder or Autism "Outpatient Prescription Drugs, Supplies, and • Dental and Orthodontic Services Supplements" in this "Benefits and Your Cost Share" section) • Dialysis Care • Radioactive materials used for therapeutic purposes • Durable Medical Equipment for Home Use • Durable medical equipment and medical supplies • Family Planning Services • Imaging, laboratory, and special procedures, • Fertility Services including MRI, CT, and PET scans • Health Education • Blood, blood products, and their administration • Hearing Services • Obstetrical care and delivery (including cesarean • Home Health Care section). Note: If you are discharged within 48 hours • Hospice Care after delivery (or within 96 hours if delivery is by cesarean section), your Plan Physician may order a • Mental Health Services follow-up visit for you and your newborn to take • Ostomy and Urological Supplies place within 48 hours after discharge (for visits after you are released from the hospital, please refer to • Outpatient Imaging, Laboratory, and Special "Outpatient Care" in this "Benefits and Your Cost Procedures Share" section)

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• Behavioral health treatment for pervasive emergency ambulance Services. However, if the provider developmental disorder or autism does not agree to bill us, you may have to pay for the Services and file a claim for reimbursement. For • Respiratory therapy information on how to file a claim, please see the "Post- • Physical, occupational, and speech therapy (including Service Claims and Appeals" section. treatment in our organized, multidisciplinary rehabilitation program) Nonemergency • Medical social services and discharge planning Inside your Home Region Service Area, we cover nonemergency ambulance and psychiatric transport van Your Cost Share. We cover hospital inpatient Services Services if a Plan Physician determines that your at 35% Coinsurance subject to the Plan Deductible. condition requires the use of Services that only a licensed ambulance (or psychiatric transport van) can provide and Coverage for Services related to "Hospital that the use of other means of transportation would Inpatient Care" described in other sections endanger your health. These Services are covered only The following types of inpatient Services are covered when the vehicle transports you to or from covered only as described under the following headings in this Services. "Benefits and Your Cost Share" section: Your Cost Share • Bariatric Surgery You pay the following for covered ambulance Services: • Dental and Orthodontic Services • Emergency ambulance Services: 35% Coinsurance • Dialysis Care subject to the Plan Deductible • Fertility Services • Nonemergency Services: 35% Coinsurance subject • Hospice Care to the Plan Deductible • Mental Health Services Ambulance Services exclusion(s) • Prosthetic and Orthotic Devices • Transportation by car, taxi, bus, gurney van, • Reconstructive Surgery wheelchair van, and any other type of transportation (other than a licensed ambulance or psychiatric • Services in Connection with a Clinical Trial transport van), even if it is the only way to travel to a • Skilled Nursing Facility Care Plan Provider • Substance Use Disorder Treatment • Transplant Services Bariatric Surgery We cover hospital inpatient care related to bariatric Ambulance Services surgical procedures (including room and board, imaging, laboratory, special procedures, and Plan Physician Emergency Services) when performed to treat obesity by We cover Services of a licensed ambulance anywhere in modification of the gastrointestinal tract to reduce the world without prior authorization (including nutrient intake and absorption, if all of the following transportation through the 911 emergency response requirements are met: system where available) in the following situations: • You complete the Medical Group–approved pre- • A reasonable person would have believed that the surgical educational preparatory program regarding medical condition was an Emergency Medical lifestyle changes necessary for long term bariatric Condition which required ambulance Services surgery success • Your treating physician determines that you must be • A Plan Physician who is a specialist in bariatric care transported to another facility because your determines that the surgery is Medically Necessary Emergency Medical Condition is not Stabilized and the care you need is not available at the treating Your Cost Share. For covered Services related to facility bariatric surgical procedures that you receive, you will pay the Cost Share you would pay if the Services were If you receive emergency ambulance Services that are not related to a bariatric surgical procedure. For not ordered by a Plan Provider, you are not responsible example, see "Hospital Inpatient Care" in this "Benefits for any amounts beyond your Cost Share for covered

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and Your Cost Share" section for the Cost Share that Section 4500) of the Welfare and Institutions Code applies for hospital inpatient care. or Title 14 (commencing with Section 95000) of the Government Code Coverage for Services related to "Bariatric • "Qualified Autism Service Paraprofessional" means Surgery" described in other sections an unlicensed and uncertified individual who meets • Outpatient prescription drugs (refer to "Outpatient all of the following criteria: Prescription Drugs, Supplies, and Supplements") ♦ is employed and supervised by a Qualified Autism • Outpatient administered drugs (refer to "Outpatient Service Provider Care") ♦ provides treatment and implements Services pursuant to a treatment plan developed and approved by the Qualified Autism Service Behavioral Health Treatment for Provider Pervasive Developmental Disorder or ♦ meets the criteria set forth in the regulations Autism adopted pursuant to Section 4686.3 of the Welfare and Institutions Code The following terms have special meaning when ♦ has adequate education, training, and experience, capitalized and used in this "Behavioral Health as certified by a Qualified Autism Service Treatment for Pervasive Developmental Disorder or Provider Autism" section: • "Qualified Autism Service Provider" means a We cover behavioral health treatment for pervasive provider who has the experience and competence to developmental disorder or autism (including applied design, supervise, provide, or administer treatment for behavior analysis and evidence-based behavior pervasive developmental disorder or autism and is intervention programs) that develops or restores, to the either of the following: maximum extent practicable, the functioning of a person ♦ a person, entity, or group that is certified by a with pervasive developmental disorder or autism and that national entity (such as the Behavior Analyst meet all of the following criteria: Certification Board) that is accredited by the • The Services are provided inside your Home Region National Commission for Certifying Agencies Service Area ♦ a person licensed in California as a physician, • The treatment is prescribed by a Plan Physician, or is physical therapist, occupational therapist, developed by a Plan Provider who is a psychologist psychologist, marriage and family therapist, educational psychologist, clinical social worker, • The treatment is provided under a treatment plan professional clinical counselor, speech-language prescribed by a Plan Provider who is a Qualified pathologist, or audiologist Autism Service Provider • "Qualified Autism Service Professional" means a • The treatment is administered by a Plan Provider who person who meets all of the following criteria: is one of the following: ♦ provides behavioral health treatment ♦ a Qualified Autism Service Provider ♦ is employed and supervised by a Qualified Autism ♦ a Qualified Autism Service Professional Service Provider supervised and employed by the Qualified Autism ♦ provides treatment pursuant to a treatment plan Service Provider developed and approved by the Qualified Autism ♦ a Qualified Autism Service Paraprofessional Service Provider supervised and employed by a Qualified Autism ♦ is a behavioral health treatment provider approved Service Provider as a vendor by a California regional center to • The treatment plan has measurable goals over a provide Services as an Associate Behavior specific timeline that is developed and approved by Analyst, Behavior Analyst, Behavior Management the Qualified Autism Service Provider for the Assistant, Behavior Management Consultant, or Member being treated Behavior Management Program as defined in • The treatment plan is reviewed no less than once Section 54342 of Title 17 of the California Code every six months by the Qualified Autism Service of Regulations Provider and modified whenever appropriate ♦ has training and experience in providing Services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with

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• The treatment plan requires the Qualified Autism Dental Services for radiation treatment Service Provider to do all of the following: We cover dental evaluation, X-rays, fluoride treatment, ♦ describe the Member's behavioral health and extractions necessary to prepare your jaw for impairments to be treated radiation therapy of cancer in your head or neck if a Plan Physician provides the Services or if the Medical Group ♦ design an intervention plan that includes the service type, number of hours, and parent authorizes a referral to a dentist (as described in participation needed to achieve the plan's goal and "Medical Group authorization procedure for certain objectives, and the frequency at which the referrals" under "Getting a Referral" in the "How to Member's progress is evaluated and reported Obtain Services" section). ♦ provide intervention plans that utilize evidence- Dental anesthesia based practices, with demonstrated clinical For dental procedures at a Plan Facility, we provide efficacy in treating pervasive developmental general anesthesia and the facility's Services associated disorder or autism with the anesthesia if all of the following are true: ♦ discontinue intensive behavioral intervention • Services when the treatment goals and objectives You are under age 7, or you are developmentally are achieved or no longer appropriate disabled, or your health is compromised • • The treatment plan is not used for either of the Your clinical status or underlying medical condition following: requires that the dental procedure be provided in a hospital or outpatient surgery center ♦ for purposes of providing (or for the reimbursement of) respite care, day care, or • The dental procedure would not ordinarily require educational services general anesthesia ♦ to reimburse a parent for participating in the treatment program We do not cover any other Services related to the dental procedure, such as the dentist's Services. Your Cost Share. You pay the following for covered behavioral health treatment program Services: no charge Accidental injury to teeth (not subject to the Plan Deductible). Services for accidental injury to teeth are not covered under this EOC. Coverage for Services related to "Behavioral Health Treatment for Pervasive Developmental Dental and orthodontic Services for cleft palate Disorder or Autism" described in other sections We cover dental extractions, dental procedures necessary to prepare the mouth for an extraction, and orthodontic • Behavioral health treatment for pervasive Services, if they meet all of the following requirements: developmental disorder or autism provided during a covered stay in a Plan Hospital or Skilled Nursing • The Services are an integral part of a reconstructive Facility (refer to "Hospital Inpatient Care" and surgery for cleft palate that we are covering under "Skilled Nursing Facility Care") "Reconstructive Surgery" in this "Benefits and Your Cost Share" section ("cleft palate" includes cleft • Outpatient drugs, supplies, and supplements (refer to palate, cleft lip, or other craniofacial anomalies "Outpatient Prescription Drugs, Supplies, and associated with cleft palate) Supplements") • A Plan Provider provides the Services or the Medical • Outpatient laboratory (refer to "Outpatient Imaging, Group authorizes a referral to a Non–Plan Provider Laboratory, and Special Procedures") who is a dentist or orthodontist (as described in • Outpatient physical, occupational, and speech therapy "Medical Group authorization procedure for certain visits (refer to "Rehabilitative and Habilitative referrals" under "Getting a Referral" in the "How to Services") Obtain Services" section)

Your Cost Share Dental and Orthodontic Services You pay the following for dental and orthodontic We do not cover most dental and orthodontic Services Services covered under this "Dental and Orthodontic Services" section: under this EOC, but we do cover some dental and orthodontic Services as described in this "Dental and • Non-Physician Specialist Visits with dentists and Orthodontic Services" section. orthodontists for Services covered under this "Dental

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and Orthodontic Services" section: a $50 Copayment Dialysis Care per visit (not subject to the Plan Deductible) We cover acute and chronic dialysis Services if all of the • Physician Specialist Visits for Services covered under following requirements are met: this "Dental and Orthodontic Services" section: a $70 Copayment per visit (not subject to the Plan • The Services are provided inside your Home Region Deductible) Service Area • Outpatient surgery and outpatient procedures when • You satisfy all medical criteria developed by the provided in an outpatient or ambulatory surgery Medical Group and by the facility providing the center or in a hospital operating room, or if it is dialysis provided in any setting and a licensed staff member • A Plan Physician provides a written referral for care monitors your vital signs as you regain sensation after at the facility receiving drugs to reduce sensation or to minimize discomfort: 35% Coinsurance subject to the Plan After you receive appropriate training at a dialysis Deductible facility we designate, we also cover equipment and • Any other outpatient surgery that does not require a medical supplies required for home hemodialysis and licensed staff member to monitor your vital signs as home peritoneal dialysis inside your Home Region described above: a $70 Copayment per procedure Service Area. Coverage is limited to the standard item of (not subject to the Plan Deductible) equipment or supplies that adequately meets your • Any other outpatient procedures that do not require a medical needs. We decide whether to rent or purchase licensed staff member to monitor your vital signs as the equipment and supplies, and we select the vendor. described above: the Cost Share that would You must return the equipment and any unused supplies otherwise apply for the procedure in this "Benefits to us or pay us the fair market price of the equipment and and Your Cost Share" section (for example, radiology any unused supply when we are no longer covering procedures that do not require a licensed staff them. member to monitor your vital signs as described above are covered under "Outpatient Imaging, Your Cost Share. You pay the following for these Laboratory, and Special Procedures") covered Services related to dialysis: • Hospital inpatient care (including room and board, • Equipment and supplies for home hemodialysis and drugs, imaging, laboratory, special procedures, and home peritoneal dialysis: no charge (not subject to Plan Physician Services): 35% Coinsurance subject the Plan Deductible) to the Plan Deductible • One routine outpatient visit per month with the multidisciplinary nephrology team for a consultation, Coverage for Services related to "Dental and evaluation, or treatment: no charge (not subject to Orthodontic Services" described in other the Plan Deductible) sections • Hemodialysis and peritoneal dialysis treatment at a • Office visits not described in the "Dental and Plan Facility: no charge (not subject to the Plan Orthodontic Services" section (refer to "Outpatient Deductible) Care") • Hospital inpatient care (including room and board, • Outpatient imaging, laboratory, and special drugs, imaging, laboratory, and special procedures, procedures (refer to "Outpatient Imaging, Laboratory, and Plan Physician Services): 35% Coinsurance and Special Procedures") subject to the Plan Deductible • Outpatient administered drugs (refer to "Outpatient Care"), except that we cover outpatient administered Coverage for Services related to "Dialysis Care" drugs under "Dental anesthesia" in this "Dental and described in other sections Orthodontic Services" section • Durable medical equipment for home use (refer to • Outpatient prescription drugs (refer to "Outpatient "Durable Medical Equipment for Home Use") Prescription Drugs, Supplies, and Supplements") • Office visits not described in the "Dialysis Care" • Telehealth Visits (refer to "Outpatient Care") section (refer to "Outpatient Care") • Outpatient laboratory (refer to "Outpatient Imaging, Laboratory, and Special Procedures")

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• Outpatient prescription drugs (refer to "Outpatient this "Durable Medical Equipment for Home Use" section Prescription Drugs, Supplies, and Supplements") are met. "Base DME Items" means the following items: • Outpatient administered drugs (refer to "Outpatient • Blood glucose monitors for diabetes blood testing and Care") their supplies (such as blood glucose monitor test strips, lancets, and lancet devices) • Telehealth Visits (refer to "Outpatient Care") • Bone stimulator Dialysis Care exclusion(s) • Canes (standard curved handle or quad) and • Comfort, convenience, or luxury equipment, supplies replacement supplies and features • Cervical traction (over door) • Nonmedical items, such as generators or accessories • Crutches (standard or forearm) and replacement to make home dialysis equipment portable for travel supplies • Dry pressure pad for a mattress Durable Medical Equipment ("DME") for • Enteral pump and supplies Home Use • Infusion pumps (such as insulin pumps) and supplies to operate the pump DME coverage rules DME for home use is an item that meets the following • IV pole criteria: • Nebulizer and supplies • The item is intended for repeated use • Peak flow meters • The item is primarily and customarily used to serve a • Phototherapy blankets for treatment of jaundice in medical purpose newborns • The item is generally useful only to an individual • Tracheostomy tube and supplies with an illness or injury • The item is appropriate for use in the home Effective January 1, 2019, the following items will be covered under "External devices" in the "Base prosthetic For a DME item to be covered, all of the following and orthotic devices" section: requirements must be met: • Enteral pump and supplies • Your EOC includes coverage for the requested DME • Tracheostomy tube and supplies item • A Plan Physician has prescribed a DME item for your Your Cost Share. You pay the following for covered medical condition Base DME Items: 35% Coinsurance (not subject to the Plan Deductible). • The item has been approved for you through the Plan's prior authorization process, as described in "Medical Group authorization procedure for certain Supplemental DME items referrals" under "Getting a Referral" in the "How to We cover only Base DME Items under this EOC. Except Obtain Services" section for breastfeeding supplies, any other DME items are supplemental DME items, and are not covered. Coverage • The Services are provided inside your Home Region for breastfeeding supplies is described under Service Area "Breastfeeding supplies" in this "Durable Medical Equipment for Home Use" section. Coverage is limited to the standard item of equipment that adequately meets your medical needs. We decide Breastfeeding supplies whether to rent or purchase the equipment, and we select We cover one retail-grade breast pump per pregnancy the vendor. You must return the equipment to us or pay and the necessary supplies to operate it, such as one set us the fair market price of the equipment when we are no of bottles. We will decide whether to rent or purchase the longer covering it. item and we choose the vendor. We cover this pump for convenience purposes. The pump is not subject to prior Base DME Items authorization requirements. We cover Base DME Items (including repair or replacement of covered equipment) if all of the requirements described under "DME coverage rules" in

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If you or your baby has a medical condition that requires Durable medical equipment for home use the use of a breast pump, we cover a hospital-grade exclusion(s) breast pump and the necessary supplies to operate it, in • Comfort, convenience, or luxury equipment or accord with the coverage rules described under "DME features except for retail-grade breast pumps as coverage rules" in this "Durable Medical Equipment of described under "Breastfeeding supplies" in this Home Use" section. "Durable Medical Equipment for Home Use" section Your Cost Share. You pay the following for covered • Repair or replacement of equipment due to loss or breastfeeding supplies: misuse • Retail-grade breast pumps and supplies: no charge (not subject to the Plan Deductible) Family Planning Services • Hospital-grade breast pumps and supplies: no charge We cover the following family planning Services subject (not subject to the Plan Deductible) to the Cost Share indicated: Outside your Home Region Service Area • Family planning counseling: no charge (not subject We do not cover most DME for home use outside your to the Plan Deductible) Home Region Service Area. However, if you live outside • Injectable contraceptives, internally implanted time- your Home Region Service Area, we cover the following release contraceptives or intrauterine devices (IUDs) DME (subject to the Cost Share and all other coverage and office visits related to their administration and requirements that apply to DME for home use inside management: no charge (not subject to the Plan your Home Region Service Area) when the item is Deductible) dispensed at a Plan Facility: • Female sterilization procedures if provided in an • Blood glucose monitors for diabetes blood testing and outpatient or ambulatory surgery center or in a their supplies (such as blood glucose monitor test hospital operating room: no charge (not subject to strips, lancets, and lancet devices) from a Plan the Plan Deductible) Pharmacy • All other female sterilization procedures: no charge • Canes (standard curved handle) (not subject to the Plan Deductible) • Crutches (standard) • Male sterilization procedures if provided in an • Insulin pumps and supplies to operate the pump, after outpatient or ambulatory surgery center or in a completion of training and education on the use of the hospital operating room: 35% Coinsurance subject pump to the Plan Deductible • Nebulizers and their supplies for the treatment of • All other male sterilization procedures: a pediatric asthma $70 Copayment per visit (not subject to the Plan Deductible) • Peak flow meters from a Plan Pharmacy • Termination of pregnancy: 35% Coinsurance Coverage for Services related to "Durable subject to the Plan Deductible Medical Equipment for Home Use" described in other sections Coverage for Services related to "Family Planning Services" described in other sections • Dialysis equipment and supplies required for home hemodialysis and home peritoneal dialysis (refer to • Services to diagnose or treat infertility (refer to "Dialysis Care") "Fertility Services") • Diabetes urine testing supplies and insulin- • Outpatient administered drugs that are not administration devices other than insulin pumps (refer contraceptives (refer to "Outpatient Care") to "Outpatient Prescription Drugs, Supplies, and • Outpatient laboratory and imaging services associated Supplements") with family planning services (refer to "Outpatient • Durable medical equipment related to the terminal Imaging, Laboratory, and Special Procedures") illness for Members who are receiving covered • Outpatient contraceptive drugs and devices (refer to hospice care (refer to "Hospice Care") "Outpatient Prescription Drugs, Supplies, and • Insulin and any other drugs administered with an Supplements") infusion pump (refer to "Outpatient Prescription Drugs, Supplies, and Supplements")

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Family Planning Services exclusion(s) Physician or other Plan Providers provide during a visit covered under another part of this EOC. • Reversal of voluntary sterilization We also cover a variety of health education counseling, Fertility Services programs, and materials to help you take an active role in protecting and improving your health, including "Fertility Services" means treatments and procedures to programs for tobacco cessation, stress management, and help you become pregnant. chronic conditions (such as diabetes and asthma). Kaiser Permanente also offers health education counseling, Diagnosis and treatment of infertility programs, and materials that are not covered, and you For purposes of this "Diagnosis and treatment of may be required to pay a fee. infertility" section, "infertility" means not being able to get pregnant or carry a pregnancy to a live birth after a For more information about our health education year or more of regular sexual relations without counseling, programs, and materials, please contact a contraception or having a medical or other demonstrated Health Education Department or our Member Service condition that is recognized by a Plan Physician as a Contact Center, refer to Your Guidebook, or go to our cause of infertility. website at kp.org.

Services for the diagnosis and treatment of infertility are Your Cost Share. You pay the following for these not covered under this EOC. covered Services: • Covered health education programs, which may Artificial insemination include programs provided online and counseling Services for artificial insemination are not covered under over the phone: no charge (not subject to the Plan this EOC. Deductible) • Individual counseling during an office visit related to Assisted reproductive technology Services smoking cessation: no charge (not subject to the Assisted reproductive technology ("ART") Services such Plan Deductible) as invitro fertilization ("IVF"), gamete intra-fallopian transfer ("GIFT"), or zygote intrafallopian transfer • Individual counseling during an office visit related to ("ZIFT") are not covered under this EOC. diabetes management: no charge (not subject to the Plan Deductible) Coverage for Services related to "Fertility • Other covered individual counseling when the office Services" described in other sections visit is solely for health education: no charge (not • Outpatient drugs, supplies, and supplements (refer to subject to the Plan Deductible) "Outpatient Prescription Drugs, Supplies, and • Health education provided during an outpatient Supplements") consultation or evaluation covered in another part of this EOC: no additional Cost Share beyond the Fertility Services exclusion(s) Cost Share required in that other part of this EOC • Services to diagnose or treat infertility • Covered health education materials: no charge (not • Services for artificial insemination subject to the Plan Deductible) • Services to reverse voluntary, surgically induced infertility Hearing Services • Semen and eggs (and Services related to their We cover the following: procurement and storage) • Hearing exams with an audiologist to determine the • Assisted reproductive technology Services, such as need for hearing correction: a $50 Copayment per ovum transplants, GIFT, IVF, and ZIFT visit (not subject to the Plan Deductible) • Physician Specialist Visits to diagnose and treat Health Education hearing problems: a $70 Copayment per visit (not subject to the Plan Deductible) We cover a variety of health education counseling, programs, and materials that your personal Plan

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Hearing aids speech therapist, and up to four hours per visit for Hearing aids and related Services are not covered under visits by a home health aide this EOC. For internally implanted devices, see • Up to three visits per day (counting all home health "Prosthetic and Orthotic Devices" in this "Benefits and visits) Your Cost Share" section. • Up to 100 visits per Accumulation Period (counting all home health visits) Coverage for Services related to "Hearing Services" described in other sections Note: If a visit by a nurse, medical social worker, or • Routine hearing screenings when performed as part of physical, occupational, or speech therapist lasts longer a routine physical maintenance exam (refer to than two hours, then each additional increment of two "Preventive Services") hours counts as a separate visit. If a visit by a home • Services related to the ear or hearing other than those health aide lasts longer than four hours, then each described in this section, such as outpatient care to additional increment of four hours counts as a separate treat an ear infection and outpatient prescription visit. For example, if a nurse comes to your home for drugs, supplies, and supplements (refer to the three hours and then leaves, that counts as two visits. applicable heading in this "Benefits and Your Cost Also, each person providing Services counts toward Share" section) these visit limits. For example, if a home health aide and a nurse are both at your home during the same two hours, • Cochlear implants and osseointegrated hearing that counts as two visits. devices (refer to "Prosthetic and Orthotic Devices") Your Cost Share. We cover home health care Services Hearing Services exclusion(s) at no charge (not subject to the Plan Deductible). • Hearing aids and tests to determine their efficacy, and hearing tests to determine an appropriate hearing aid Coverage for Services related to "Home Health Care" described in other sections Home Health Care • Behavioral health treatment for pervasive developmental disorder or autism (refer to "Home health care" means Services provided in the "Behavioral Health Treatment for Pervasive home by nurses, medical social workers, home health Developmental Disorder or Autism") aides, and physical, occupational, and speech therapists. • Dialysis care (refer to "Dialysis Care") We cover home health care only if all of the following are true: • Durable medical equipment (refer to "Durable Medical Equipment for Home Use") • You are substantially confined to your home (or a friend's or relative's home) • Ostomy and urological supplies (refer to "Ostomy and Urological Supplies") • Your condition requires the Services of a nurse, physical therapist, occupational therapist, or speech • Outpatient drugs, supplies, and supplements (refer to therapist (home health aide Services are not covered "Outpatient Prescription Drugs, Supplies, and unless you are also getting covered home health care Supplements") from a nurse, physical therapist, occupational • Outpatient physical, occupational, and speech therapy therapist, or speech therapist that only a licensed visits (refer to "Rehabilitative and Habilitative provider can provide) Services") • A Plan Physician determines that it is feasible to • Prosthetic and orthotic devices (refer to "Prosthetic maintain effective supervision and control of your and Orthotic Devices") care in your home and that the Services can be safely and effectively provided in your home Home health care exclusion(s) • The Services are provided inside your Home Region • Care of a type that an unlicensed family member or Service Area other layperson could provide safely and effectively in the home setting after receiving appropriate We cover only part-time or intermittent home health training. This care is excluded even if we would care, as follows: cover the care if it were provided by a qualified • Up to two hours per visit for visits by a nurse, medical professional in a hospital or a Skilled medical social worker, or physical, occupational, or Nursing Facility

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• Care in the home if the home is not a safe and to a 100-day supply in accord with our drug effective treatment setting formulary guidelines. You must obtain these drugs from a Plan Pharmacy. Certain drugs are limited to a maximum 30-day supply in any 30-day period (please Hospice Care call our Member Service Contact Center for the current list of these drugs) Hospice care is a specialized form of interdisciplinary health care designed to provide palliative care and to • Durable medical equipment alleviate the physical, emotional, and spiritual • Respite care when necessary to relieve your discomforts of a Member experiencing the last phases of caregivers. Respite care is occasional short-term life due to a terminal illness. It also provides support to inpatient care limited to no more than five the primary caregiver and the Member's family. A consecutive days at a time Member who chooses hospice care is choosing to receive • Counseling and bereavement services palliative care for pain and other symptoms associated with the terminal illness, but not to receive care to try to • Dietary counseling cure the terminal illness. You may change your decision to receive hospice care benefits at any time. We also cover the following hospice Services only during periods of crisis when they are Medically We cover the hospice Services listed below at no charge Necessary to achieve palliation or management of acute (not subject to the Plan Deductible) only if all of the medical symptoms: following requirements are met: • Nursing care on a continuous basis for as much as 24 • A Plan Physician has diagnosed you with a terminal hours a day as necessary to maintain you at home illness and determines that your life expectancy is 12 • Short-term inpatient care required at a level that months or less cannot be provided at home • The Services are provided inside your Home Region Service Area or inside California but within 15 miles or 30 minutes from your Home Region Service Area Mental Health Services (including a friend's or relative's home even if you We cover Services specified in this "Mental Health live there temporarily) Services" section only when the Services are for the • The Services are provided by a licensed hospice diagnosis or treatment of Mental Disorders. A "Mental agency that is a Plan Provider Disorder" is a mental health condition identified as a • A Plan Physician determines that the Services are "mental disorder" in the Diagnostic and Statistical necessary for the palliation and management of your Manual of Mental Disorders, Fourth Edition, Text terminal illness and related conditions Revision, as amended in the most recently issued edition, (DSM) that results in clinically significant distress or If all of the above requirements are met, we cover the impairment of mental, emotional, or behavioral following hospice Services, if necessary for your hospice functioning. We do not cover services for conditions that care: the DSM identifies as something other than a "mental disorder." For example, the DSM identifies relational • Plan Physician Services problems as something other than a "mental disorder," so • Skilled nursing care, including assessment, we do not cover services (such as couples counseling or evaluation, and case management of nursing needs, family counseling) for relational problems. treatment for pain and symptom control, provision of emotional support to you and your family, and "Mental Disorders" include the following conditions: instruction to caregivers • Severe Mental Illness of a person of any age • Physical, occupational, and speech therapy for • Serious Emotional Disturbance of a Child Under Age purposes of symptom control or to enable you to 18 maintain activities of daily living • Respiratory therapy In addition to the Services described in this Mental • Medical social services Health Services section, we also cover other Services that are Medically Necessary to treat Severe Mental • Home health aide and homemaker services Illness or a Serious Emotional Disturbance of a Child • Palliative drugs prescribed for pain control and Under Age 18, if the Medical Group authorizes a written symptom management of the terminal illness for up referral (as described in "Medical Group authorization

Group ID: 799999, 399999, 799997, & 399997 Kaiser Permanente Deductible HMO Plan Kaiser Permanente Silver 70 HMO 1000/50 Alt Date: August 29, 2017 Page 37

procedure for certain referrals" under "Getting a • Drugs prescribed by a Plan Provider as part of your Referral" in the "How to Obtain Services" section). plan of care in the residential treatment facility in accord with our drug formulary guidelines if they are Outpatient mental health Services administered to you in the facility by medical We cover the following Services when provided by Plan personnel (for discharge drugs prescribed when you Physicians or other Plan Providers who are licensed are released from the residential treatment facility, health care professionals acting within the scope of their please refer to "Outpatient Prescription Drugs, license: Supplies, and Supplements" in this "Benefits and Your Cost Share" section) • Individual and group mental health evaluation and treatment • Discharge planning • Psychological testing when necessary to evaluate a Mental Disorder Your Cost Share. We cover residential mental health treatment Services at 35% Coinsurance subject to the • Outpatient Services for the purpose of monitoring Plan Deductible. drug therapy Inpatient psychiatric hospitalization Intensive psychiatric treatment programs. We cover We cover inpatient psychiatric hospitalization in a Plan the following intensive psychiatric treatment programs at Hospital. Coverage includes room and board, drugs, and a Plan Facility: Services of Plan Physicians and other Plan Providers • Partial hospitalization who are licensed health care professionals acting within the scope of their license. • Multidisciplinary treatment in an intensive outpatient program Your Cost Share. We cover inpatient psychiatric • Psychiatric observation for an acute psychiatric crisis hospital Services at 35% Coinsurance subject to the Plan Deductible. Your Cost Share. You pay the following for these covered Services: Coverage for Services related to "Mental Health • Individual mental health evaluation and treatment: a Services" described in other sections $50 Copayment per visit (not subject to the Plan • Outpatient drugs, supplies, and supplements (refer to Deductible) "Outpatient Prescription Drugs, Supplies, and • Group mental health treatment: a $25 Copayment Supplements") per visit (not subject to the Plan Deductible) • Outpatient laboratory (refer to "Outpatient Imaging, • Partial hospitalization: no charge (not subject to the Laboratory, and Special Procedures") Plan Deductible) • Telehealth Visits (refer to "Outpatient Care") • Other intensive psychiatric treatment programs: no charge (not subject to the Plan Deductible) Ostomy and Urological Supplies Residential treatment We cover ostomy and urological supplies if the Inside your Home Region Service Area, we cover the following requirements are met: following Services when the Services are provided in a • licensed residential treatment facility that provides 24- A Plan Physician has prescribed ostomy and hour individualized mental health treatment, the Services urological supplies for your medical condition are generally and customarily provided by a mental • The item has been approved for you through the health residential treatment program in a licensed Plan's prior authorization process, as described in residential treatment facility, and the Services are above "Medical Group authorization procedure for certain the level of custodial care: referrals" under "Getting a Referral" in the "How to • Individual and group mental health evaluation and Obtain Services" section treatment • The Services are provided inside your Home Region • Medical services Service Area

• Medication monitoring Coverage is limited to the standard item of equipment • Room and board that adequately meets your medical needs. We decide • Social services

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whether to rent or purchase the equipment, and we select • All other diagnostic procedures provided by Plan the vendor. Providers who are not physicians (such as EKGs and EEGs): Your Cost Share: You pay the following for covered ♦ if the diagnostic procedures are provided in an ostomy and urological supplies: no charge (not subject outpatient or ambulatory surgery center or in a to the Plan Deductible). hospital operating room, or if they are provided in any setting and a licensed staff member monitors Ostomy and urological supplies exclusion(s) your vital signs as you regain sensation after • Comfort, convenience, or luxury equipment or receiving drugs to reduce sensation or to minimize features discomfort: 35% Coinsurance subject to the Plan Deductible ♦ if the diagnostic procedures do not require a Outpatient Imaging, Laboratory, and licensed staff member to monitor your vital signs Special Procedures as described above: a $65 Copayment per encounter (not subject to the Plan Deductible) We cover the following Services at the Cost Share • indicated only when prescribed as part of care covered Radiation therapy: no charge (not subject to the under other headings in this "Benefits and Your Cost Plan Deductible) Share" section: • Ultraviolet light treatments: no charge (not subject • Certain outpatient imaging and laboratory Services to the Plan Deductible) are Preventive Services. You can find more information about the Preventive Services we cover Coverage for Services related to "Outpatient under "Preventive Services" in this "Benefits and Imaging, Laboratory, and Special Procedures" Your Cost Share" section described in other sections • All other CT scans, and all MRIs and PET scans: a • Services related to diagnosis and treatment of $350 Copayment per procedure subject to the Plan infertility, artificial insemination, or ART Services Deductible (refer to "Fertility Services") • All other imaging Services, such as diagnostic and therapeutic X-rays, mammograms, and ultrasounds: Outpatient Prescription Drugs, Supplies, ♦ if the imaging Services are provided in an and Supplements outpatient or ambulatory surgery center or in a hospital operating room, or if they are provided in We cover outpatient drugs, supplies, and supplements any setting and a licensed staff member monitors specified in this "Outpatient Prescription Drugs, your vital signs as you regain sensation after Supplies, and Supplements" section when prescribed as receiving drugs to reduce sensation or to minimize follows and obtained at a Plan Pharmacy or through our discomfort: 35% Coinsurance subject to the mail-order service: Plan Deductible • Items prescribed by Plan Providers, within the scope ♦ if the imaging Services do not require a licensed of their licensure and practice, and in accord with our staff member to monitor your vital signs as drug formulary guidelines described above: a $65 Copayment per • Items prescribed by the following Non–Plan encounter (not subject to the Plan Deductible) Providers unless a Plan Physician determines that the • Nuclear medicine: a $65 Copayment per encounter item is not Medically Necessary or the drug is for a (not subject to the Plan Deductible) sexual dysfunction disorder: • Routine retinal photography screenings: no charge ♦ Dentists if the drug is for dental care (not subject to the Plan Deductible) ♦ Non–Plan Physicians if the Medical Group • Routine laboratory tests to monitor the effectiveness authorizes a written referral to the Non–Plan of dialysis: no charge (not subject to the Plan Physician (in accord with "Medical Group Deductible) authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain • All other laboratory tests (including tests for specific Services" section) and the drug, supply, or genetic disorders for which genetic counseling is supplement is covered as part of that referral available): a $50 Copayment per encounter (not ♦ Non–Plan Physicians if the prescription was subject to the Plan Deductible) obtained as part of covered Emergency Services,

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Post-Stabilization Care, or Out-of-Area Urgent prescribed up to the day supply limit also specified in Care described in the "Emergency Services and this section. The maximum you may receive at one time Urgent Care" section (if you fill the prescription at of a covered item is either one 30-day supply in a 30-day a Plan Pharmacy, you may have to pay Charges period or one 100-day supply in a 100-day period. If you for the item and file a claim for reimbursement as wish to receive more than the covered day supply limit, described under "Payment and Reimbursement" in then you must pay Charges for any prescribed quantities the "Emergency Services and Urgent Care" that exceed the day supply limit. Note: We cover section) episodic drugs prescribed for the treatment of sexual dysfunction disorders up to a maximum of 8 doses in any How to obtain covered items 30-day period or up to 27 doses in any 100-day period. You must obtain covered items at a Plan Pharmacy or through our mail-order service unless you obtain the item The pharmacy may reduce the day supply dispensed at as part of covered Emergency Services, Post- the Cost Share specified in this "Outpatient Prescription Stabilization Care, or Out-of-Area Urgent Care described Drugs, Supplies, and Supplements" section to a 30-day in the "Emergency Services and Urgent Care" section. supply in any 30-day period if the pharmacy determines that the item is in limited supply in the market or for Please refer to Your Guidebook or the facility directory specific drugs (your Plan Pharmacy can tell you if a drug on our website at kp.org for the locations of Plan you take is one of these drugs). Pharmacies in your area. About the drug formulary Refills. You may be able to order refills at a Plan The drug formulary includes a list of drugs that our Pharmacy, through our mail-order service, or through our Pharmacy and Therapeutics Committee has approved for website at kp.org/rxrefill. A Plan Pharmacy or Your our Members. Our Pharmacy and Therapeutics Guidebook can give you more information about Committee, which is primarily composed of Plan obtaining refills, including the options available to you Physicians, selects drugs for the drug formulary based on for obtaining refills. For example, a few Plan Pharmacies a number of factors, including safety and effectiveness as don't dispense refills and not all drugs can be mailed determined from a review of medical literature. The through our mail-order service. Please check with a Plan Pharmacy and Therapeutics Committee meets at least Pharmacy if you have a question about whether your quarterly to consider additions and deletions based on prescription can be mailed or obtained at a Plan new information or drugs that become available. To find Pharmacy. Items available through our mail-order out which drugs are on the formulary for your plan, service are subject to change at any time without notice. please visit our website at kp.org/formulary. If you would like to request a copy of the drug formulary for Day supply limit your plan, please call our Member Service Contact Hormonal contraceptives. The prescribing physician Center. Note: The presence of a drug on the drug determines how much of a contraceptive drug or item to formulary does not necessarily mean that your Plan prescribe. For purposes of day supply coverage limits, Physician will prescribe it for a particular medical Plan Physicians determine the amount of contraceptives condition. that constitute Medically Necessary 30-day or 100-day or 365-day supply for you. Upon payment of the Cost Share Drug formulary guidelines allow you to obtain specified in this "Outpatient Prescription Drugs, nonformulary prescription drugs (those not listed on our Supplies, and Supplements" section, you will receive the drug formulary for your condition) if they would supply prescribed up to the day supply limit also otherwise be covered and a Plan Physician determines specified in this section. The maximum you may receive that they are Medically Necessary. If you disagree with at one time for hormonal contraceptives is a 365-day your Plan Physician's determination that a nonformulary supply. prescription drug is not Medically Necessary, you may file a grievance as described in the "Dispute Resolution" All other items. The prescribing physician or dentist section. Also, our formulary guidelines may require you determines how much of a drug, supply, or supplement to participate in a behavioral intervention program to prescribe. For purposes of day supply coverage limits, approved by the Medical Group for specific conditions Plan Physicians determine the amount of an item that and you may be required to pay for the program. constitutes a Medically Necessary 30- or 100-day supply for you. Upon payment of the Cost Share specified in About specialty drugs this "Outpatient Prescription Drugs, Supplies, and Specialty drugs are high-cost drugs that are on our Supplements" section, you will receive the supply specialty drug list. To obtain a list of specialty drugs that

Group ID: 799999, 399999, 799997, & 399997 Kaiser Permanente Deductible HMO Plan Kaiser Permanente Silver 70 HMO 1000/50 Alt Date: August 29, 2017 Page 40

are on our formulary, or to find out if a nonformulary You may request mail-order service in the following drug is on the specialty drug list, please call our Member ways: Service Contact Center. If your Plan Physician prescribes • To order online, visit kp.org/rxrefill (you can more than a 30-day supply for an outpatient drug, you register for a secure account at kp.org/registernow) may be able to obtain more than a 30-day supply at one or use the KP app from your smartphone or other time, up to the day supply limit for that drug. However, mobile device most specialty drugs are limited to a 30-day supply in any 30-day period. Your Plan Pharmacy can tell you if a • Call the pharmacy phone number highlighted on your drug you take is one of these drugs. prescription label and select the mail delivery option • On your next visit to a Kaiser Permanente pharmacy, General rules about coverage and your Cost ask our staff how you can have your prescriptions Share mailed to you We cover the following outpatient drugs, supplies, and supplements as described in this "Outpatient Prescription Note: Not all drugs can be mailed; restrictions and Drugs, Supplies, and Supplements" section: limitations apply. • Drugs for which a prescription is required by law. We also cover certain drugs that do not require a Drug Deductible. In any Accumulation Period, you prescription by law if they are listed on our drug must pay Charges for any items covered under this formulary "Outpatient Prescription Drugs, Supplies, and Supplements" section that are subject to the Drug • Disposable needles and syringes needed for injecting Deductible until you meet one of the following Drug covered drugs and supplements Deductible amounts: • Inhaler spacers needed to inhale covered drugs Self-only coverage (a Family of one Member): Note: • $250 per Accumulation Period • If Charges for the drug, supply, or supplement are less than the Copayment, you will pay the lesser Family coverage (a Family of two or more Members): amount • $250 per Accumulation Period for each Member in • Items can change tier at any time, in accord with the Family formulary guidelines, which may impact your Cost • $500 per Accumulation Period for the entire Family Share (for example, if a brand-name drug is added to the specialty drug list, you will pay the Cost Share The only payments that count toward this Drug that applies to drugs on the specialty drug tier, not the Deductible are those you make under this EOC for Cost Share for drugs on the brand-name drug tier) covered items that are subject to this Drug Deductible. After you reach the Drug Deductible, you pay the Continuity drugs. If this EOC is amended to exclude a applicable Copayments or Coinsurance for these items drug that we have been covering and providing to you for the remainder of the Accumulation Period. under this EOC, we will continue to provide the drug if a prescription is required by law and a Plan Physician Services that are subject to the Drug Deductible. The continues to prescribe the drug for the same condition Cost Share that you must pay for covered Services is and for a use approved by the federal Food and Drug described in this EOC. When the Cost Share for the Administration: Services is described as "subject to the Drug • Generic continuity drugs: 50% Coinsurance (not to Deductible," your Cost Share for those Services will be exceed $50) for up to a 100-day supply (not subject Charges until you reach the Drug Deductible. Note: to the Drug Deductible) When the Cost Share for the Services is described as "no • Brand-name continuity drugs: 50% Coinsurance charge subject to the Drug Deductible," your Cost Share (not to exceed $100) for up to a 100-day supply for those Services will be Charges until you reach the subject to the Drug Deductible Drug Deductible.

Mail-order service. Prescription refills can be mailed within 7 to 10 days at no extra cost for standard U.S. postage. The appropriate Cost Share (according to your drug coverage) will apply and must be charged to a valid credit card.

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Coverage and your Cost Share for most items • Immunosuppressants and ganciclovir and ganciclovir Drugs, supplies, and supplements are covered as follows prodrugs for the treatment of cytomegalovirus when except for items listed under "Other items:" prescribed in connection with a transplant • Phosphate binders for dialysis patients for the If your Plan Physician prescribes more than a 30-day treatment of hyperphosphatemia in end stage renal supply for an outpatient drug, you may be able to obtain disease more than a 30-day supply at one time up to the day supply limit for that drug. Applicable Cost Share will Your Cost Share Your Cost Share apply. For example, two 30-day copayments may be due Item at a Plan By Mail when picking up a 60-day prescription, three copayments Pharmacy may be due when picking up a 100-day prescription at Hematopoietic the pharmacy. agents for dialysis No charge for up Not available (not subject to the to a 30-day supply Your Cost Share Drug Deductible) Your Cost Share Item at a Plan Elemental dietary By Mail Pharmacy enteral formula when used as a No charge for up Items on the generic primary therapy for Not available to a 30-day supply tier (not subject to $25 for up to a $50 for up to a regional enteritis the Drug 30-day supply 100-day supply (not subject to the Deductible) Drug Deductible) Items on the brand- Availability for All other items on name tier subject to $70 for up to a $140 for up to a mail order varies the generic tier (not $25 for up to a the Drug 30-day supply 100-day supply by item. Talk to subject to the Drug 30-day supply Deductible your local Availability for Deductible) Items on the 20% Coinsurance pharmacy mail order varies Availability for specialty tier (not to exceed All other items on by item. Talk to mail order varies subject to the Drug $250) for up to a the brand-name tier $70 for up to a your local by item. Talk to Deductible 30-day supply (not subject to the 30-day supply pharmacy your local Drug Deductible) pharmacy Other items Availability for All other items on 20% Coinsurance Coverage and your Cost Share listed above for most mail order varies the specialty tier (not to exceed items does not apply to the items list under "Other by item. Talk to subject to the Drug $250) for up to a items." Coverage and your Cost Share for these other your local Deductible 30-day supply items is as follows: pharmacy

Base drugs, supplies, and supplements Anticancer drugs and certain critical adjuncts We cover the following items at the Cost Share following a diagnosis of cancer indicated: Your Cost Share Your Cost Share • Certain drugs for the treatment of life-threatening Item at a Plan By Mail ventricular arrhythmia Pharmacy Oral anticancer Availability for • Drugs for the treatment of tuberculosis drugs on the generic mail order varies $25 for up to a • Elemental dietary enteral formula when used as a tier (not subject to by item. Talk to 30-day supply primary therapy for regional enteritis the Drug your local • Hematopoietic agents for dialysis Deductible) pharmacy Oral anticancer Availability for • Hematopoietic agents for the treatment of anemia in drugs on the brand- mail order varies chronic renal insufficiency $70 for up to a name tier (not by item. Talk to 30-day supply • Human growth hormone for long-term treatment of subject to the Drug your local pediatric patients with growth failure from lack of Deductible) pharmacy adequate endogenous growth hormone secretion

Group ID: 799999, 399999, 799997, & 399997 Kaiser Permanente Deductible HMO Plan Kaiser Permanente Silver 70 HMO 1000/50 Alt Date: August 29, 2017 Page 42

Your Cost Share Diabetes supplies and amino acid–modified products Your Cost Share Item at a Plan Your Cost Share By Mail Your Cost Share Pharmacy Item at a Plan By Mail Oral anticancer Availability for Pharmacy 20% Coinsurance drugs on the mail order varies Amino acid– (not to exceed specialty tier (not by item. Talk to modified products $200) for up to a subject to the Drug your local used to treat 30-day supply Deductible) pharmacy congenital errors of No charge for up amino acid Not available Non-oral anticancer Availability for to a 30-day supply drugs on the generic mail order varies metabolism (such as $25 for up to a tier (not subject to by item. Talk to phenylketonuria) 30-day supply the Drug your local (not subject to the Deductible) pharmacy Drug Deductible) Non-oral anticancer Availability for Ketone test strips drugs on the brand- mail order varies and sugar or acetone $70 for up to a name tier (not by item. Talk to test tablets or tapes No charge for up 30-day supply subject to the Drug your local for diabetes urine to a 100-day Not available Deductible) pharmacy testing (not subject supply Non-oral anticancer Availability for to the Drug 20% Coinsurance drugs on the mail order varies Deductible) (not to exceed specialty tier by item. Talk to Insulin- $250) for up to a subject to the Drug your local administration 30-day supply Deductible pharmacy devices: pen delivery devices, Availability for disposable needles Home infusion drugs mail order varies and syringes, and $25 for up to a Home infusion drugs are self-administered intravenous by item. Talk to visual aids required 100-day supply drugs, fluids, additives, and nutrients that require specific your local to ensure proper types of parenteral-infusion, such as an intravenous or pharmacy intraspinal-infusion. dosage (except eyewear) (not Your Cost Share Your Cost Share subject to the Drug Item at a Plan By Mail Deductible) Pharmacy Note: Drugs related to the treatment of diabetes (for Home infusion example, insulin) are not covered under this "Diabetes drugs (not subject No charge for up Not available supplies and amino-acid modified products" section. to the Drug to a 30-day supply Deductible) Contraceptive drugs and devices Supplies necessary Your Cost Share for administration of Your Cost Share Item at a Plan home infusion drugs No charge No charge By Mail (not subject to the Pharmacy Drug Deductible) The following hormonal contraceptive items for women on the No charge for up generic tier when to a 365-day No charge for up prescribed by a Plan supply to a 365-day Provider (not Rings are not supply subject to the Drug available for mail Deductible): order • Rings • Patches • Oral contraceptives

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Your Cost Share Certain preventive items Your Cost Share Item at a Plan Your Cost Share By Mail Your Cost Share Pharmacy Item at a Plan By Mail The following Pharmacy contraceptive items Items on our for women on the Preventive Services generic tier when under Health prescribed by a Plan Reform list on our No charge for up No charge for up Provider (not website at to a 100-day Not available to a 100-day Not available subject to the Drug kp.org/prevention supply supply Deductible): when prescribed by • Female condoms a Plan Provider (not subject to the Drug • Spermicide Deductible) • Sponges The following Fertility and sexual dysfunction drugs hormonal Your Cost Share contraceptive items Your Cost Share Item at a Plan for women on the By Mail No charge for up Pharmacy brand-name tier to a 365-day Drugs on the generic when prescribed by No charge for up supply tier prescribed to a Plan Provider (not to a 365-day Rings are not treat infertility or in subject to the Drug supply available for mail connection with Not covered Not covered Deductible): order covered artificial • Rings insemination • Patches Services • Oral contraceptives Drugs on the brand- The following name and specialty contraceptive items tiers prescribed to treat infertility or in for women on the Not covered Not covered brand-name tier connection with covered artificial when prescribed by No charge for up insemination a Plan Provider (not to a 100-day Not available Services subject to the Drug supply Deductible): Drugs on the generic • Female condoms tier prescribed in connection with • Spermicide covered assisted Not covered Not covered • Sponges reproductive Emergency technology (ART) contraception (not No charge Not available Services subject to the Drug Drugs on the brand- Deductible) name and specialty Diaphragms and tiers prescribed in cervical caps (not connection with No charge Not available Not covered Not covered subject to the Drug covered assisted Deductible) reproductive technology (ART) Services Drugs on the generic tier prescribed for sexual dysfunction $25 for up to a $50 for up to a disorders (not 30-day supply 100-day supply subject to the Drug Deductible)

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Your Cost Share Your Cost Share Preventive Services Item at a Plan By Mail Pharmacy We cover a variety of Preventive Services, including but Drugs on the brand- not limited to the following: name and specialty • Services recommended by the United States tiers prescribed for $70 for up to a $140 for up to a Preventive Services Task Force with rating of "A" or sexual dysfunction 30-day supply 100-day supply "B." The complete list of these services can be found disorders subject to at uspreventiveservicestaskforce.org the Drug • Immunizations listed on the Recommended Deductible Childhood Immunization Schedule/United States, jointly adopted by the American Academy of Coverage for Services related to "Outpatient Pediatrics, the Advisory Committee on Immunization Prescription Drugs, Supplies, and Supplements" Practices, and the American Academy of Family described in other sections Physicians • Administered contraceptives (refer to "Family • Preventive services for women recommended by the Planning Services") Health Resources and Services Administration and • Diabetes blood-testing equipment and their supplies, incorporated into the Affordable Care Act. The and insulin pumps and their supplies (refer to complete list of these services can be found at "Durable Medical Equipment for Home Use") hrsa.gov/womensguidelines • Drugs covered during a covered stay in a Plan Hospital or Skilled Nursing Facility (refer to The list of Preventive Services recommended by the "Hospital Inpatient Care" and "Skilled Nursing above organizations is subject to change. These Facility Care") Preventive Services are subject to all coverage requirements described in this "Benefits and Your Cost • Drugs prescribed for pain control and symptom Share" section and all provisions in the "Exclusions, management of the terminal illness for Members who Limitations, Coordination of Benefits, and Reductions" are receiving covered hospice care (refer to "Hospice section. You may obtain a list of Preventive Services we Care") cover on our website at kp.org/prevention. If you have • Durable medical equipment used to administer drugs questions about Preventive Services, please call our (refer to "Durable Medical Equipment for Home Member Service Contact Center. Use") • Outpatient administered drugs that are not Note: If you receive any other covered Services that are contraceptives (refer to "Outpatient Care") not Preventive Services during or subsequent to a visit that includes Preventive Services on the list, you will pay the applicable Cost Share for those other Services. For Outpatient prescription drugs, supplies, and example, if laboratory tests or imaging Services ordered supplements exclusion(s) during a preventive office visit are not Preventive • Any requested packaging (such as dose packaging) Services, you will pay the applicable Cost Share for other than the dispensing pharmacy's standard those Services. packaging • Compounded products unless the drug is listed on our Your Cost Share. You pay the following for covered drug formulary or one of the ingredients requires a Preventive Services: prescription by law • Preventive Services received during an office visit: • Drugs prescribed to shorten the duration of the ♦ routine physical exams, including well-woman common cold exams: no charge (not subject to the Plan • All drugs, supplies, and supplements for diagnosis Deductible) and treatment of infertility or related to artificial ♦ well child preventive exams for Members through insemination age 23 months: no charge (not subject to the Plan Deductible) • All drugs, supplies, and supplements related to assisted reproductive technology (ART) Services ♦ after confirmation of pregnancy, the normal series of regularly scheduled preventive prenatal care exams: no charge (not subject to the Plan Deductible)

Group ID: 799999, 399999, 799997, & 399997 Kaiser Permanente Deductible HMO Plan Kaiser Permanente Silver 70 HMO 1000/50 Alt Date: August 29, 2017 Page 45

♦ the first postpartum follow-up consultation and contraceptive drugs and implanted contraceptive exam: no charge (not subject to the Plan devices Deductible) ♦ other contraceptive drugs and devices for women: ♦ immunizations (including the vaccine) refer to "Outpatient drugs, supplies, and administered to you in a Plan Medical Office: supplements" in this "Benefits and Your Cost no charge (not subject to the Plan Deductible) Share" section for coverage and Cost Share ♦ tuberculosis skin tests: no charge (not subject to information for all other contraceptive drugs and the Plan Deductible) devices ♦ screening and counseling Services when provided • Other Preventive Services: during a routine physical exam or a well-child ♦ breast pumps and breastfeeding supplies: refer to preventive exam, such as obesity counseling, Breastfeeding supplies" under "Durable Medical routine vision screenings, alcohol and substance Equipment for Home Use" in this "Benefits and abuse screenings, health education, depression Your Cost Share" section for coverage and Cost screening, and developmental screenings to Share information diagnose and assess potential developmental delays: no charge (not subject to the Plan Coverage related to "Preventive Services" Deductible) described in other sections ♦ routine hearing screenings: no charge (not • Breast pumps and breastfeeding supplies (refer to subject to the Plan Deductible) "Breastfeeding supplies" under "Durable Medical • Outpatient procedures that are Preventive Services: Equipment for Home Use") ♦ sterilization procedures for women: refer to • Health education programs (refer to "Health "Family Planning Services" in this "Benefits and Education") Your Cost Share" section for coverage and Cost • Outpatient drugs, supplies, and supplements that are Share information Preventive Services (refer to "Outpatient Prescription ♦ screening colonoscopies: no charge (not subject Drugs, Supplies, and Supplements") to the Plan Deductible) • Women's family planning counseling, consultations, ♦ screening flexible sigmoidoscopies: no charge and sterilization Services (refer to "Family Planning (not subject to the Plan Deductible) Services") • Outpatient imaging and laboratory Services that are Preventive Services ♦ routine imaging screenings such as mammograms: Prosthetic and Orthotic Devices no charge (not subject to the Plan Deductible) Prosthetic and orthotic devices coverage rules ♦ bone density CT scans: no charge (not subject to We cover the prosthetic and orthotic devices specified in the Plan Deductible) this "Prosthetic and Orthotic Devices" section if all of the ♦ bone density DEXA scans: no charge (not following requirements are met: subject to the Plan Deductible) • The device is in general use, intended for repeated ♦ routine laboratory tests and screenings such as use, and primarily and customarily used for medical cancer screening tests, sexually transmitted purposes infection (STI) tests, cholesterol screening tests, • The device is the standard device that adequately and glucose tolerance tests: no charge (not meets your medical needs subject to the Plan Deductible) • You receive the device from the provider or vendor ♦ other laboratory screening tests, such as fecal occult blood tests and hepatitis B screening tests: that we select no charge (not subject to the Plan Deductible) • The item has been approved for you through the • Outpatient prescription drugs, supplies and Plan's prior authorization process, as described in supplements that are Preventive Services: "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to ♦ implanted contraceptive drugs and devices for Obtain Services" section women: refer to "Family Planning Services" in this "Benefits and Your Cost Share" section for • The Services are provided inside your Home Region coverage and Cost Share for provider-administered Service Area

Group ID: 799999, 399999, 799997, & 399997 Kaiser Permanente Deductible HMO Plan Kaiser Permanente Silver 70 HMO 1000/50 Alt Date: August 29, 2017 Page 46

Coverage includes fitting and adjustment of these Prior to January 1, 2019, the following items are covered devices, their repair or replacement, and Services to under "Base DME Items" in the "Durable Medical determine whether you need a prosthetic or orthotic Equipment for Home Use" section of this EOC: device. If we cover a replacement device, then you pay • Enteral pump and supplies the Cost Share that you would pay for obtaining that device. • Tracheostomy tube and supplies

Base prosthetic and orthotic devices Supplemental prosthetic and orthotic devices If all of the requirements described under "Prosthetic and If all of the requirements described under "Prosthetic and orthotic coverage rules" in this "Prosthetics and Orthotic orthotic coverage rules" in this "Prosthetics and Orthotic Devices" section are met, we cover the items described Devices" section are met, we cover the following items in this "Base prosthetic and orthotic devices" section. described in this "Supplemental prosthetic and orthotic devices" section: Internally implanted devices. We cover prosthetic and • Prosthetic devices required to replace all or part of an orthotic devices such as pacemakers, intraocular lenses, organ or extremity, but only if they also replace the cochlear implants, osseointegrated hearing devices, and function of the organ or extremity (including external hip joints, if they are implanted during a surgery that we sexual dysfunction devices effective January 1, 2019) are covering under another section of this "Benefits and • Rigid and semi-rigid orthotic devices required to Your Cost Share" section. We cover these devices at support or correct a defective body part no charge subject to the Plan Deductible. • Covered special footwear when custom made for foot External devices. We cover the following external disfigurement due to disease, injury, or prosthetic and orthotic devices at no charge (not subject developmental disability to the Plan Deductible): Prior to January 1, 2019, external sexual dysfunction • Prosthetic devices and installation accessories to devices are covered under "Supplemental DME items" in restore a method of speaking following the removal the "Durable Medical Equipment for Home Use" section of all or part of the larynx (this coverage does not of this EOC. include electronic voice-producing machines, which are not prosthetic devices) Your Cost Share. You pay the following for covered • After a Medically Necessary mastectomy: supplemental prosthetic and orthotic devices: no charge ♦ prostheses, including custom-made prostheses (not subject to the Plan Deductible). when Medically Necessary ♦ up to three brassieres required to hold a prosthesis Coverage for Services related to "Prosthetic and in any 12-month period Orthotic Devices" described in other sections • Podiatric devices (including footwear) to prevent or • Eyeglasses and contact lenses, including contact treat diabetes-related complications when prescribed lenses to treat aniridia or aphakia (refer to "Vision by a Plan Physician or by a Plan Provider who is a Services for Adult Members" and "Vision Services podiatrist for Pediatric Members") • Compression burn garments and lymphedema wraps • Hearing aids other than internally implanted devices and garments described in this section (refer to "Hearing Services") • Enteral formula for Members who require tube • Injectable implants (refer to "Administered drugs and feeding in accord with Medicare guidelines products" under "Outpatient Care") • Enteral pump and supplies (effective January 1, 2019) Prosthetic and orthotic devices exclusion(s) • Tracheostomy tube and supplies (effective January 1, • Multifocal intraocular lenses and intraocular lenses to 2019) correct astigmatism • Prostheses to replace all or part of an external facial • Nonrigid supplies, such as elastic stockings and wigs, body part that has been removed or impaired as a except as otherwise described above in this result of disease, injury, or congenital defect "Prosthetic and Orthotic Devices" section • Comfort, convenience, or luxury equipment or features • Repair or replacement of device due to loss or misuse

Group ID: 799999, 399999, 799997, & 399997 Kaiser Permanente Deductible HMO Plan Kaiser Permanente Silver 70 HMO 1000/50 Alt Date: August 29, 2017 Page 47

• Shoes, shoe inserts, arch supports, or any other Coverage for Services related to footwear, even if custom-made, except footwear "Reconstructive Surgery" described in other described above in this "Prosthetic and Orthotic sections Devices" section for diabetes-related complications • Dental and orthodontic Services that are an integral and foot disfigurement part of reconstructive surgery for cleft palate (refer to • Prosthetic and orthotic devices not intended for "Dental and Orthodontic Services") maintaining normal activities of daily living • Office visits not described in the "Reconstructive (including devices intended to provide additional Surgery" section (refer to "Outpatient Care") support for recreational or sports activities) • Outpatient imaging and laboratory (refer to "Outpatient Imaging, Laboratory, and Special Reconstructive Surgery Procedures") We cover the following reconstructive surgery Services: • Outpatient prescription drugs (refer to "Outpatient Prescription Drugs, Supplies, and Supplements") • Reconstructive surgery to correct or repair abnormal structures of the body caused by congenital defects, • Outpatient administered drugs (refer to "Outpatient developmental abnormalities, trauma, infection, Care") tumors, or disease, if a Plan Physician determines that • Prosthetics and orthotics (refer to "Prosthetic and it is necessary to improve function, or create a normal Orthotic Devices") appearance, to the extent possible • Telehealth Visits (refer to "Outpatient Care") • Following Medically Necessary removal of all or part of a breast, we cover reconstruction of the breast, Reconstructive surgery exclusion(s) surgery and reconstruction of the other breast to • produce a symmetrical appearance, and treatment of Surgery that, in the judgment of a Plan Physician physical complications, including lymphedemas specializing in reconstructive surgery, offers only a minimal improvement in appearance Your Cost Share. You pay the following for covered reconstructive surgery Services: Rehabilitative and Habilitative Services • Outpatient surgery and outpatient procedures when provided in an outpatient or ambulatory surgery We cover the Services described in this "Rehabilitative center or in a hospital operating room, or if it is and Habilitative Services" section if all of the following provided in any setting and a licensed staff member requirements are met: monitors your vital signs as you regain sensation after • The Services are to address a health condition receiving drugs to reduce sensation or to minimize • The Services are to help you keep, learn, or improve discomfort: 35% Coinsurance subject to the Plan skills and functioning for daily living Deductible • You receive the Services at a Plan Facility unless a • Any other outpatient surgery that does not require a Plan Physician determines that it is Medically licensed staff member to monitor your vital signs as Necessary for you to receive the Services in another described above: a $70 Copayment per procedure location (not subject to the Plan Deductible) • Any other outpatient procedures that do not require a We cover the following Services at the Cost Share licensed staff member to monitor your vital signs as indicated: described above: the Cost Share that would • Individual outpatient physical, occupational, and otherwise apply for the procedure in this "Benefits and Your Cost Share" section (for example, radiology speech therapy: a $65 Copayment per visit (not procedures that do not require a licensed staff subject to the Plan Deductible) member to monitor your vital signs as described • Group outpatient physical, occupational, and speech above are covered under "Outpatient Imaging, therapy: a $32 Copayment per visit (not subject to Laboratory, and Special Procedures") the Plan Deductible) • Hospital inpatient care (including room and board, • Physical, occupational, and speech therapy provided drugs, imaging, laboratory, special procedures, and in an organized, multidisciplinary rehabilitation day- Plan Physician Services): 35% Coinsurance subject treatment program: a $65 Copayment per day (not to the Plan Deductible subject to the Plan Deductible)

Group ID: 799999, 399999, 799997, & 399997 Kaiser Permanente Deductible HMO Plan Kaiser Permanente Silver 70 HMO 1000/50 Alt Date: August 29, 2017 Page 48

Coverage for Services related to "Rehabilitative "Approved Clinical Trial" means a phase I, phase II, and Habilitative Services" described in other phase III, or phase IV clinical trial related to the sections prevention, detection, or treatment of cancer or other life-threatening condition, and that meets one of the • Behavioral health treatment for pervasive following requirements: developmental disorder or autism (refer to "Behavioral Health Treatment for Pervasive • The study or investigation is conducted under an Developmental Disorder or Autism") investigational new drug application reviewed by the U.S. Food and Drug Administration • Home health care (refer to "Home Health Care") • The study or investigation is a drug trial that is • Durable medical equipment (refer to "Durable exempt from having an investigational new drug Medical Equipment for Home Use") application • Ostomy and urological supplies (refer to "Ostomy and • The study or investigation is approved or funded by at Urological Supplies") least one of the following: • Prosthetic and orthotic devices (refer to "Prosthetic ♦ the National Institutes of Health and Orthotic Devices") ♦ the Centers for Disease Control and Prevention • Physical, occupational, and speech therapy provided ♦ the Agency for Health Care Research and Quality during a covered stay in a Plan Hospital or Skilled Nursing Facility (refer to "Hospital Inpatient Care" ♦ the Centers for Medicare & Medicaid Services and "Skilled Nursing Facility Care") ♦ a cooperative group or center of any of the above entities or of the Department of Defense or the Rehabilitative and Habilitative Services Department of Veterans Affairs exclusion(s) ♦ a qualified non-governmental research entity • Items and services that are not health care items and identified in the guidelines issued by the National services (for example, respite care, day care, Institutes of Health for center support grants recreational care, residential treatment, social ♦ the Department of Veterans Affairs or the services, custodial care, or education services of any Department of Defense or the Department of kind, including vocational training) Energy, but only if the study or investigation has been reviewed and approved though a system of peer review that the U.S. Secretary of Health and Services in Connection with a Clinical Human Services determines meets all of the Trial following requirements: (1) It is comparable to the National Institutes of Health system of peer review We cover Services you receive in connection with a of studies and investigations and (2) it assures clinical trial if all of the following requirements are met: unbiased review of the highest scientific standards • We would have covered the Services if they were not by qualified people who have no interest in the related to a clinical trial outcome of the review • You are eligible to participate in the clinical trial Your Cost Share. For covered Services related to a according to the trial protocol with respect to clinical trial, you will pay the Cost Share you would treatment of cancer or other life-threatening condition pay if the Services were not related to a clinical trial. (a condition from which the likelihood of death is For example, see "Hospital Inpatient Care" in this probable unless the course of the condition is "Benefits and Your Cost Share" section for the Cost interrupted), as determined in one of the following Share that applies for hospital inpatient care. ways: ♦ a Plan Provider makes this determination Services in connection with a clinical trial ♦ you provide us with medical and scientific exclusion(s) information establishing this determination • The investigational Service • If any Plan Providers participate in the clinical trial • Services that are provided solely to satisfy data and will accept you as a participant in the clinical collection and analysis needs and are not used in your trial, you must participate in the clinical trial through clinical management a Plan Provider unless the clinical trial is outside the state where you live • The clinical trial is an Approved Clinical Trial

Group ID: 799999, 399999, 799997, & 399997 Kaiser Permanente Deductible HMO Plan Kaiser Permanente Silver 70 HMO 1000/50 Alt Date: August 29, 2017 Page 49

Skilled Nursing Facility Care • Outpatient physical, occupational, and speech therapy (refer to "Rehabilitative and Habilitative Services") Inside your Home Region Service Area, we cover up to 100 days per benefit period (including any days we covered under any other Health Plan evidence of Substance Use Disorder Treatment coverage offered by your Group) of skilled inpatient Services in a Plan Skilled Nursing Facility. The skilled We cover Services specified in this "Substance Use inpatient Services must be customarily provided by a Disorder Treatment" section only when the Services are Skilled Nursing Facility, and above the level of custodial for the diagnosis or treatment of Substance Use or intermediate care. Disorders. A "Substance Use Disorder" is a condition identified as a "substance use disorder" in the most A benefit period begins on the date you are admitted to a recently issued edition of the Diagnostic and Statistical hospital or Skilled Nursing Facility at a skilled level of Manual of Mental Disorders ("DSM"). care. A benefit period ends on the date you have not been an inpatient in a hospital or Skilled Nursing Facility, Outpatient substance use disorder treatment receiving a skilled level of care, for 60 consecutive days. We cover the following Services for treatment of A new benefit period can begin only after any existing substance use disorders: benefit period ends. A prior three-day stay in an acute • Day-treatment programs care hospital is not required. • Individual and group substance use disorder We cover the following Services: counseling • Intensive outpatient programs • Physician and nursing Services • Medical treatment for withdrawal symptoms • Room and board

• Drugs prescribed by a Plan Physician as part of your Your Cost Share. You pay the following for these plan of care in the Plan Skilled Nursing Facility in covered Services: accord with our drug formulary guidelines if they are administered to you in the Plan Skilled Nursing • Individual substance use disorder evaluation and Facility by medical personnel treatment: a $50 Copayment per visit (not subject to the Plan Deductible) • Durable medical equipment in accord with our durable medical equipment formulary if Skilled • Group substance use disorder treatment: a Nursing Facilities ordinarily furnish the equipment $5 Copayment per visit (not subject to the Plan Deductible) • Imaging and laboratory Services that Skilled Nursing Facilities ordinarily provide • Intensive outpatient and day-treatment programs: no charge (not subject to the Plan Deductible) • Medical social services • Blood, blood products, and their administration Residential treatment • Medical supplies Inside your Home Region Service Area, we cover the following Services when the Services are provided in a • Behavioral health treatment for pervasive licensed residential treatment facility that provides 24- developmental disorder or autism hour individualized substance use disorder treatment, the • Physical, occupational, and speech therapy Services are generally and customarily provided by a substance use disorder residential treatment program in a • Respiratory therapy licensed residential treatment facility, and the Services are above the level of custodial care: Your Cost Share. We cover skilled nursing facility Services at 35% Coinsurance subject to the Plan • Individual and group substance use disorder Deductible. counseling • Medical services Coverage for Services related to "Skilled • Medication monitoring Nursing Facility Care" described in other sections • Room and board • Outpatient imaging, laboratory, and special • Social services procedures (refer to "Outpatient Imaging, Laboratory, • Drugs prescribed by a Plan Provider as part of your and Special Procedures") plan of care in the residential treatment facility in

Group ID: 799999, 399999, 799997, & 399997 Kaiser Permanente Deductible HMO Plan Kaiser Permanente Silver 70 HMO 1000/50 Alt Date: August 29, 2017 Page 50

accord with our drug formulary guidelines if they are furnishing, or ensuring the availability of an organ, administered to you in the facility by medical tissue, or bone marrow donor personnel (for discharge drugs prescribed when you • In accord with our guidelines for Services for living are released from the residential treatment facility, transplant donors, we provide certain donation-related please refer to "Outpatient Prescription Drugs, Services for a donor, or an individual identified by Supplies, and Supplements" in this "Benefits and the Medical Group as a potential donor, whether or Your Cost Share" section) not the donor is a Member. These Services must be • Discharge planning directly related to a covered transplant for you, which may include certain Services for harvesting the organ, Your Cost Share. We cover residential substance use tissue, or bone marrow and for treatment of disorder treatment Services at 35% Coinsurance complications. Please call our Member Service subject to the Plan Deductible. Contact Center for questions about donor Services

Inpatient detoxification Your Cost Share. For covered transplant Services that We cover hospitalization in a Plan Hospital only for you receive, you will pay the Cost Share you would pay medical management of withdrawal symptoms, including if the Services were not related to a transplant. For room and board, Plan Physician Services, drugs, example, see "Hospital Inpatient Care" in this "Benefits dependency recovery Services, education, and and Your Cost Share" section for the Cost Share that counseling. applies for hospital inpatient care.

Your Cost Share. We cover inpatient detoxification We provide or pay for donation-related Services for Services at 35% Coinsurance subject to the Plan actual or potential donors (whether or not they are Deductible. Members) in accord with our guidelines for donor Services at no charge (not subject to the Plan Coverage for Services related to "Substance Deductible). Use Disorder Treatment" described in other sections Coverage for Services related to "Transplant Services" described in other sections • Outpatient laboratory (refer to "Outpatient Imaging, Laboratory, and Special Procedures") • Outpatient imaging and laboratory (refer to "Outpatient Imaging, Laboratory, and Special • Outpatient self-administered drugs (refer to Procedures") "Outpatient Prescription Drugs, Supplies, and Supplements") • Outpatient prescription drugs (refer to "Outpatient Prescription Drugs, Supplies, and Supplements") • Telehealth Visits (refer to "Outpatient Care") • Outpatient administered drugs (refer to "Outpatient Care") Transplant Services We cover transplants of organs, tissue, or bone marrow Vision Services for Adult Members if the Medical Group provides a written referral for care to a transplant facility as described in "Medical Group We cover the following for Adult Members: authorization procedure for certain referrals" under • Routine eye exams with a Plan Optometrist to "Getting a Referral" in the "How to Obtain Services" determine the need for vision correction (including section. dilation Services when Medically Necessary) and to provide a prescription for eyeglass lenses: no charge After the referral to a transplant facility, the following (not subject to the Plan Deductible) applies: • Physician Specialist Visits to diagnose and treat • If either the Medical Group or the referral facility injuries or diseases of the eye: a $70 Copayment per determines that you do not satisfy its respective visit (not subject to the Plan Deductible) criteria for a transplant, we will only cover Services • Non-Physician Specialist Visits to diagnose and treat you receive before that determination is made injuries or diseases of the eye: a $50 Copayment per • Health Plan, Plan Hospitals, the Medical Group, and visit (not subject to the Plan Deductible) Plan Physicians are not responsible for finding,

Group ID: 799999, 399999, 799997, & 399997 Kaiser Permanente Deductible HMO Plan Kaiser Permanente Silver 70 HMO 1000/50 Alt Date: August 29, 2017 Page 51

Optical Services Vision Services for Pediatric Members We cover the Services described in this "Optical Services" section at Plan Medical Offices or Plan Optical We cover the following for Pediatric Members: Sales Offices. • Routine eye exams with a Plan Optometrist to determine the need for vision correction (including We do not cover eyeglasses or contact lenses under this dilation Services when Medically Necessary) and to EOC (except for special contact lenses described in this provide a prescription for eyeglass lenses: no charge "Vision Services for Adult Members" section). (not subject to the Plan Deductible) • Physician Specialist Visits to diagnose and treat

Special contact lenses: injuries or diseases of the eye: a $70 Copayment per • For aniridia (missing iris), we cover up to two visit (not subject to the Plan Deductible) Medically Necessary contact lenses per eye • Non-Physician Specialist Visits to diagnose and treat (including fitting and dispensing) in any 12-month injuries or diseases of the eye: a $50 Copayment per period when prescribed by a Plan Physician or Plan visit (not subject to the Plan Deductible) Optometrist at no charge (not subject to the Plan Deductible) Optical Services • For aphakia (absence of the crystalline lens of the We cover the Services described in this "Optical eye), we cover up to six Medically Necessary aphakic Services" section at Plan Medical Offices or Plan Optical contact lenses per eye (including fitting and Sales Offices. dispensing) in any 12-month period at no charge (not subject to the Plan Deductible) when prescribed by Special contact lenses: a Plan Physician or Plan Optometrist • For aniridia (missing iris), we cover up to two Medically Necessary contact lenses per eye Low vision devices (including fitting and dispensing) in any 12-month Low vision devices (including fitting and dispensing) are period when prescribed by a Plan Physician or Plan not covered under this EOC. Optometrist at no charge (not subject to the Plan Deductible) Coverage for Services related to "Vision Services for Adult Members" described in other • For aphakia (absence of the crystalline lens of the sections eye), we cover up to six Medically Necessary aphakic contact lenses per eye (including fitting and • Routine vision screenings when performed as part of dispensing) in any 12-month period at no charge (not a routine physical exam (refer to "Preventive subject to the Plan Deductible) when prescribed by Services") a Plan Physician or Plan Optometrist • Services related to the eye or vision other than • If a Plan Physician or Plan Optometrist prescribes Services covered under this "Vision Services for contact lenses (other than contact lenses for aniridia Adult Members" section, such as outpatient surgery and aphakia) that will provide a significant and outpatient prescription drugs, supplies, and improvement in your vision that eyeglass lenses supplements (refer to the applicable heading in this cannot provide, we cover either one pair of contact "Benefits and Your Cost Share" section) lenses (including fitting and dispensing) or an initial supply of disposable contact lenses (including fitting Vision Services for Adult Members exclusion(s) and dispensing) in any 12-month period at no charge • Contact lenses, including fitting and dispensing, (not subject to the Plan Deductible) except as described under this "Vision Services for Adult Members" section Eyeglasses and contact lenses. If you prefer to wear • Eyeglass lenses and frames eyeglasses rather than contact lenses, we cover one complete pair of eyeglasses (frame and Regular Eyeglass • Eye exams for the purpose of obtaining or Lenses) from our designated value frame collection at maintaining contact lenses no charge (not subject to the Plan Deductible) every • Industrial frames 12 months when prescribed by a physician or optometrist and a Plan Provider puts the lenses into an eyeglass • Low vision devices frame. We cover a clear balance lens when only one eye needs correction. We cover tinted lenses when Medically

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Necessary to treat macular degeneration or retinitis • Except for Regular Eyeglass Lenses described in this pigmentosa. "Vision Services for Pediatric Members" section, all other lenses such as progressive and High-Index "Regular Eyeglass Lenses" are lenses that meet all of the lenses following requirements: • Eyeglass or contact lens adornment, such as • They are clear glass, plastic, or polycarbonate lenses engraving, faceting, or jeweling • At least one of the two lenses has refractive value • Industrial frames • They are single vision, flat top multifocal, or • Items that do not require a prescription by law (other lenticular than eyeglass frames), such as eyeglass holders, eyeglass cases, and repair kits Eyeglass warranty: Eyeglasses purchased at a Plan • Lenses and sunglasses without refractive value, Optical Sales Office may include a replacement warranty except as described in this "Vision Services for for up to one year from the original date of dispensing. Pediatric Members" section Please ask your Plan Optical Sales Office for warranty information. • Photochromic or polarized lenses • Replacement of broken or damaged contact lenses, Other contact lenses. If you prefer to wear contact eyeglass lenses, and frames, except as described in lenses rather than eyeglasses, we cover the following warranty information provided to you at the time of (including fitting and dispensing) at no charge (not purchase subject to the Plan Deductible) when prescribed by a • Replacement of broken or damaged low vision physician or optometrist and obtained at a Plan Medical devices Office or Plan Optical Sales Office: • Replacement of lost or stolen eyewear • Standard contact lenses: one pair of lenses in any 12- month period; or • Disposable contact lenses: one 6-month supply for each eye in any 12-month period Exclusions, Limitations, Coordination of Benefits, and Low vision devices Reductions If a low-vision device will provide a significant improvement in your vision not obtainable with eyeglasses or contact lenses (or with a combination of Exclusions eyeglasses and contact lenses), we cover one device The items and services listed in this "Exclusions" section (including fitting and dispensing) per Accumulation are excluded from coverage. These exclusions apply to Period at no charge (not subject to the Plan all Services that would otherwise be covered under this Deductible). EOC regardless of whether the services are within the scope of a provider's license or certificate. Additional Coverage for Services related to "Vision exclusions that apply only to a particular benefit are Services for Pediatric Members" described in listed in the description of that benefit in this EOC. other sections These exclusions or limitations do not apply to Services • Routine vision screenings when performed as part of that are Medically Necessary to treat Severe Mental a routine physical exam (refer to "Preventive Illness or Serious Emotional Disturbance of a Child Services") Under Age 18. • Services related to the eye or vision other than Certain exams and Services Services covered under this "Vision Services for Pediatric Members" section, such as outpatient Physical exams and other Services (1) required for surgery and outpatient prescription drugs, supplies, obtaining or maintaining employment or participation in and supplements (refer to the applicable heading in employee programs, (2) required for insurance or this "Benefits and Your Cost Share" section) licensing, or (3) on court order or required for parole or probation. This exclusion does not apply if a Plan Physician determines that the Services are Medically Vision Services for Pediatric Members Necessary. exclusion(s) • Antireflective coating

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Chiropractic Services Use," "Home Health Care," "Hospice Care," "Ostomy Chiropractic Services and the Services of a chiropractor, and Urological Supplies," and "Outpatient Prescription unless you have coverage for supplemental chiropractic Drugs, Supplies, and Supplements" in the "Benefits and Services as described in an amendment to this EOC. Your Cost Share" section.

Cosmetic Services Experimental or investigational Services Services that are intended primarily to change or A Service is experimental or investigational if we, in maintain your appearance (including Cosmetic Surgery, consultation with the Medical Group, determine that one which is defined as surgery that is performed to alter or of the following is true: reshape normal structures of the body in order to • Generally accepted medical standards do not improve appearance), except that this exclusion does not recognize it as safe and effective for treating the apply to any of the following: condition in question (even if it has been authorized • Services covered under "Reconstructive Surgery" in by law for use in testing or other studies on human the "Benefits and Your Cost Share" section patients) • The following devices covered under "Prosthetic and • It requires government approval that has not been Orthotic Devices" in the "Benefits and Your Cost obtained when the Service is to be provided Share" section: testicular implants implanted as part of a covered reconstructive surgery, breast prostheses This exclusion does not apply to any of the following: needed after a mastectomy, and prostheses to replace • Experimental or investigational Services when an all or part of an external facial body part investigational application has been filed with the federal Food and Drug Administration (FDA) and the Custodial care manufacturer or other source makes the Services Assistance with activities of daily living (for example: available to you or Kaiser Permanente through an walking, getting in and out of bed, bathing, dressing, FDA-authorized procedure, except that we do not feeding, toileting, and taking medicine). cover Services that are customarily provided by research sponsors free of charge to enrollees in a This exclusion does not apply to assistance with clinical trial or other investigational treatment activities of daily living that is provided as part of protocol covered hospice, Skilled Nursing Facility, or inpatient • Services covered under "Services in Connection with hospital care. a Clinical Trial" in the "Benefits and Your Cost Share" section Dental and orthodontic Services Dental and orthodontic Services such as X-rays, Please refer to the "Dispute Resolution" section for appliances, implants, Services provided by dentists or information about Independent Medical Review related orthodontists, dental Services following accidental injury to denied requests for experimental or investigational to teeth, and dental Services resulting from medical Services. treatment such as surgery on the jawbone and radiation treatment. Hair loss or growth treatment Items and services for the promotion, prevention, or This exclusion does not apply to Services covered under other treatment of hair loss or hair growth. "Dental and Orthodontic Services" in the "Benefits and Your Cost Share" section, or to pediatric dental Services Intermediate care described in a Pediatric Dental Services Amendment to this EOC, if any. If your plan has a Pediatric Dental Care in a licensed intermediate care facility. This Services Amendment, it will be attached to this EOC, exclusion does not apply to Services covered under and it will be listed in the EOC's Table of Contents. "Durable Medical Equipment for Home Use," "Home Health Care," and "Hospice Care" in the "Benefits and Your Cost Share" section. Disposable supplies Disposable supplies for home use, such as bandages, Items and services that are not health care items gauze, tape, antiseptics, dressings, Ace-type bandages, and services and diapers, underpads, and other incontinence supplies. For example, we do not cover: This exclusion does not apply to disposable supplies • Teaching manners and etiquette covered under "Durable Medical Equipment for Home

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• Teaching and support services to develop planning This exclusion does not apply to any of the following: skills such as daily activity planning and project or • Amino acid–modified products and elemental dietary task planning enteral formula covered under "Outpatient • Items and services for the purpose of increasing Prescription Drugs, Supplies, and Supplements" in academic knowledge or skills the "Benefits and Your Cost Share" section • Teaching and support services to increase intelligence • Enteral formula covered under "Prosthetic and Orthotic Devices" in the "Benefits and Your Cost • Academic coaching or tutoring for skills such as Share" section grammar, math, and time management • Teaching you how to read, whether or not you have Residential care dyslexia Care in a facility where you stay overnight, except that • Educational testing this exclusion does not apply when the overnight stay is part of covered care in a hospital, a Skilled Nursing • Teaching art, dance, horse riding, music, play or Facility, inpatient respite care covered in the "Hospice swimming, except that this exclusion for "teaching Care" section, or residential treatment program Services play" does not apply to Services that are part of a covered in the "Substance Use Disorder Treatment" and behavioral health therapy treatment plan and covered "Mental Health Services" sections. under "Behavioral Health Treatment for Pervasive Developmental Disorder or Autism" in the "Benefits and Your Cost Share" section Routine foot care items and services Routine foot care items and services that are not • Teaching skills for employment or vocational Medically Necessary. purposes • Vocational training or teaching vocational skills Services not approved by the federal Food and Drug Administration • Professional growth courses Drugs, supplements, tests, vaccines, devices, radioactive • Training for a specific job or employment counseling materials, and any other Services that by law require • Aquatic therapy and other water therapy, except that federal Food and Drug Administration (FDA) approval this exclusion for aquatic therapy and other water in order to be sold in the U.S. but are not approved by the therapy does not apply to therapy Services that are FDA. This exclusion applies to Services provided part of a physical therapy treatment plan and covered anywhere, even outside the U.S. under "Hospital Inpatient Care," "Home Health Care," "Hospice Services," "Rehabilitative and This exclusion does not apply to any of the following: Habilitative Services," or "Skilled Nursing Facility • Services covered under the "Emergency Services and Care" in the "Benefits and Your Cost Share" section Urgent Care" section that you receive outside the U.S.

Items and services to correct refractive defects • Experimental or investigational Services when an of the eye investigational application has been filed with the Items and services (such as eye surgery or contact lenses FDA and the manufacturer or other source makes the to reshape the eye) for the purpose of correcting Services available to you or Kaiser Permanente refractive defects of the eye such as myopia, hyperopia, through an FDA-authorized procedure, except that we or astigmatism. do not cover Services that are customarily provided by research sponsors free of charge to enrollees in a clinical trial or other investigational treatment Massage therapy protocol Massage therapy, except that this exclusion does not apply to therapy Services that are part of a physical • Services covered under "Services in Connection with therapy treatment plan and covered under "Hospital a Clinical Trial" in the "Benefits and Your Cost Inpatient Care," "Home Health Care," "Hospice Share" section Services," or "Rehabilitative and Habilitative Services," or "Skilled Nursing Facility Care" in the "Benefits and Please refer to the "Dispute Resolution" section for Your Cost Share" section. information about Independent Medical Review related to denied requests for experimental or investigational Oral nutrition Services. Outpatient oral nutrition, such as dietary supplements, herbal supplements, weight loss aids, formulas, and food.

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Services performed by unlicensed people provision of Services under this EOC, such as a major Services that are performed safely and effectively by disaster, epidemic, war, riot, civil insurrection, disability people who do not require licenses or certificates by the of a large share of personnel at a Plan Facility, complete state to provide health care services and where the or partial destruction of facilities, and labor dispute. Member's condition does not require that the services be Under these circumstances, if you have an Emergency provided by a licensed health care provider. Medical Condition, call 911 or go to the nearest hospital as described under "Emergency Services" in the This exclusion does not apply to Services covered under "Emergency Services and Urgent Care" section, and we "Behavioral Health Treatment for Pervasive will provide coverage and reimbursement as described in Developmental Disorder or Autism" in the "Benefits and that section. Your Cost Share" section. Additional limitations that apply only to a particular Services related to a noncovered Service benefit are listed in the description of that benefit in this When a Service is not covered, all Services related to the EOC. noncovered Service are excluded, except for Services we would otherwise cover to treat complications of the noncovered Service. For example, if you have a Coordination of Benefits noncovered cosmetic surgery, we would not cover The Services covered under this EOC are subject to Services you receive in preparation for the surgery or for coordination of benefits rules. follow-up care. If you later suffer a life-threatening complication such as a serious infection, this exclusion Coverage other than Medicare coverage would not apply and we would cover any Services that If you have medical or dental coverage under another we would otherwise cover to treat that complication. plan that is subject to coordination of benefits, we will coordinate benefits with the other coverage under the Surrogacy coordination of benefits rules of the California Services for anyone in connection with a Surrogacy Department of Managed Health Care. Those rules are Arrangement, except for otherwise-covered Services incorporated into this EOC. provided to a Member who is a surrogate. A "Surrogacy Arrangement" is one in which a woman (the surrogate) If both the other coverage and we cover the same agrees to become pregnant and to surrender the baby (or Service, the other coverage and we will see that up to babies) to another person or persons who intend to raise 100 percent of your covered medical expenses are paid the child (or children), whether or not the woman for that Service. The coordination of benefits rules receives payment for being a surrogate. Please refer to determine which coverage pays first, or is "primary," and "Surrogacy arrangements" under "Reductions" in this which coverage pays second, or is "secondary." The "Exclusions, Limitations, Coordination of Benefits, and secondary coverage may reduce its payment to take into Reductions" section for information about your account payment by the primary coverage. You must obligations to us in connection with a Surrogacy give us any information we request to help us coordinate Arrangement, including your obligations to reimburse us benefits. for any Services we cover and to provide information about anyone who may be financially responsible for If your coverage under this EOC is secondary, we may Services the baby (or babies) receive. be able to establish a Benefit Reserve Account for you. You may draw on the Benefit Reserve Account during a Travel and lodging expenses calendar year to pay for your out-of-pocket expenses for Travel and lodging expenses, except as described in our Services that are partially covered by either your other Travel and Lodging Program Description. The Travel coverage or us during that calendar year. If you are and Lodging Program Description is available online at entitled to a Benefit Reserve Account, we will provide kp.org/specialty-care/travel-reimbursements or by you with detailed information about this account. calling our Member Service Contact Center. If you have any questions about coordination of benefits, please call our Member Service Contact Center. Limitations We will make a good faith effort to provide or arrange Medicare coverage for covered Services within the remaining availability of If you have Medicare coverage, we will coordinate facilities or personnel in the event of unusual benefits with the Medicare coverage under Medicare circumstances that delay or render impractical the rules. Medicare rules determine which coverage pays

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first, or is "primary," and which coverage pays second, or Within 30 days after submitting or filing a claim or legal is "secondary." You must give us any information we action against a third party, you must send written notice request to help us coordinate benefits. Please call our of the claim or legal action to: Member Service Contact Center to find out which For Northern California Home Region Members: Medicare rules apply to your situation, and how payment Trover Solutions, Inc. will be handled. Kaiser Permanente - Northern California Region Subrogation Mailbox Reductions 9390 Bunsen Parkway Louisville, KY 40220 Employer responsibility For Southern California Home Region Members: For any Services that the law requires an employer to The Rawlings Group provide, we will not pay the employer, and when we Subrogation Mailbox cover any such Services we may recover the value of the P.O. Box 2000 Services from the employer. LaGrange, KY 40031 Government agency responsibility In order for us to determine the existence of any rights For any Services that the law requires be provided only we may have and to satisfy those rights, you must by or received only from a government agency, we will complete and send us all consents, releases, not pay the government agency, and when we cover any authorizations, assignments, and other documents, such Services we may recover the value of the Services including lien forms directing your attorney, the third from the government agency. party, and the third party's liability insurer to pay us directly. You may not agree to waive, release, or reduce Injuries or illnesses alleged to be caused by our rights under this provision without our prior, written third parties consent. If you obtain a judgment or settlement from or on behalf of a third party who allegedly caused an injury or illness If your estate, parent, guardian, or conservator asserts a for which you received covered Services, you must claim against a third party based on your injury or reimburse us to the maximum extent allowed under illness, your estate, parent, guardian, or conservator and California Civil Code Section 3040. Note: This "Injuries any settlement or judgment recovered by the estate, or illnesses alleged to be caused by third parties" section parent, guardian, or conservator shall be subject to our does not affect your obligation to pay your Cost Share liens and other rights to the same extent as if you had for these Services. asserted the claim against the third party. We may assign our rights to enforce our liens and other rights. To the extent permitted or required by law, we have the option of becoming subrogated to all claims, causes of If you have Medicare, Medicare law may apply with action, and other rights you may have against a third respect to Services covered by Medicare. party or an insurer, government program, or other source of coverage for monetary damages, compensation, or Some providers have contracted with Kaiser Permanente indemnification on account of the injury or illness to provide certain Services to Members at rates that are allegedly caused by the third party. We will be so typically less than the fees that the providers ordinarily subrogated as of the time we mail or deliver a written charge to the general public ("General Fees"). However, notice of our exercise of this option to you or your these contracts may allow the providers to recover all or attorney. a portion of the difference between the fees paid by Kaiser Permanente and their General Fees by means of a To secure our rights, we will have a lien on the proceeds lien claim under California Civil Code Sections 3045.1– of any judgment or settlement you or we obtain against a 3045.6 against a judgment or settlement that you receive third party. The proceeds of any judgment or settlement from or on behalf of a third party. For Services the that you or we obtain shall first be applied to satisfy our provider furnished, our recovery and the provider's lien, regardless of whether the total amount of the recovery together will not exceed the provider's General proceeds is less than the actual losses and damages you Fees. incurred. Surrogacy arrangements If you enter into a Surrogacy Arrangement and you or any other payee are entitled to receive payments or other

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compensation under the Surrogacy Arrangement, you You must send this information to: must reimburse us for covered Services you receive For Northern California Home Region Members: related to conception, pregnancy, delivery, or postpartum Trover Solutions, Inc. care in connection with that arrangement ("Surrogacy Health Services") to the maximum extent allowed under Kaiser Permanente - Northern California Region California Civil Code Section 3040. A "Surrogacy Surrogacy Mailbox 9390 Bunsen Parkway Arrangement" is one in which a woman agrees to become pregnant and to surrender the baby (or babies) to Louisville, KY 40220 another person or persons who intend to raise the child For Southern California Home Region Members: (or children), whether or not the woman receives The Rawlings Group payment for being a surrogate. Note: This "Surrogacy Surrogacy Mailbox arrangements" section does not affect your obligation to P.O. Box 2000 pay your Cost Share for these Services. After you LaGrange, KY 40031 surrender a baby to the legal parents, you are not obligated to reimburse us for any Services that the baby You must complete and send us all consents, releases, receives (the legal parents are financially responsible for authorizations, lien forms, and other documents that are any Services that the baby receives). reasonably necessary for us to determine the existence of any rights we may have under this "Surrogacy By accepting Surrogacy Health Services, you arrangements" section and to satisfy those rights. You automatically assign to us your right to receive payments may not agree to waive, release, or reduce our rights that are payable to you or any other payee under the under this "Surrogacy arrangements" section without our Surrogacy Arrangement, regardless of whether those prior, written consent. payments are characterized as being for medical expenses. To secure our rights, we will also have a lien If your estate, parent, guardian, or conservator asserts a on those payments and on any escrow account, trust, or claim against a third party based on the surrogacy any other account that holds those payments. Those arrangement, your estate, parent, guardian, or payments (and amounts in any escrow account, trust, or conservator and any settlement or judgment recovered by other account that holds those payments) shall first be the estate, parent, guardian, or conservator shall be applied to satisfy our lien. The assignment and our lien subject to our liens and other rights to the same extent as will not exceed the total amount of your obligation to us if you had asserted the claim against the third party. We under the preceding paragraph. may assign our rights to enforce our liens and other rights. Within 30 days after entering into a Surrogacy Arrangement, you must send written notice of the If you have questions about your obligations under this arrangement, including all of the following information: provision, please contact our Member Service Contact • Names, addresses, and telephone numbers of the Center. other parties to the arrangement U.S. Department of Veterans Affairs • Names, addresses, and telephone numbers of any escrow agent or trustee For any Services for conditions arising from military service that the law requires the Department of Veterans • Names, addresses, and telephone numbers of the Affairs to provide, we will not pay the Department of intended parents and any other parties who are Veterans Affairs, and when we cover any such Services financially responsible for Services the baby (or we may recover the value of the Services from the babies) receive, including names, addresses, and Department of Veterans Affairs. telephone numbers for any health insurance that will cover Services that the baby (or babies) receive Workers' compensation or employer's liability • A signed copy of any contracts and other documents benefits explaining the arrangement You may be eligible for payments or other benefits, • Any other information we request in order to satisfy including amounts received as a settlement (collectively our rights referred to as "Financial Benefit"), under workers' compensation or employer's liability law. We will provide covered Services even if it is unclear whether you are entitled to a Financial Benefit, but we may recover the value of any covered Services from the following sources:

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• From any source providing a Financial Benefit or • A court-appointed guardian may file for his or her from whom a Financial Benefit is due ward, except that the ward must appoint the court- • From you, to the extent that a Financial Benefit is appointed guardian as authorized representative if the provided or payable or would have been required to ward has the legal right to control release of be provided or payable if you had diligently sought to information that is relevant to the claim establish your rights to the Financial Benefit under • A court-appointed conservator may file for his or her any workers' compensation or employer's liability law conservatee • An agent under a currently effective health care proxy, to the extent provided under state law, may file Post-Service Claims and Appeals for his or her principal

This "Post-Service Claims and Appeals" section explains Authorized representatives must be appointed in writing how to file a claim for payment or reimbursement for using either our authorization form or some other form of Services that you have already received. Please use the written notification. The authorization form is available procedures in this section in the following situations: from the Member Services Department at a Plan Facility, on our website at kp.org, or by calling our Member • You have received Emergency Services, Post- Service Contact Center. Your written authorization must Stabilization Care, Out-of-Area Urgent Care, or accompany the claim. You must pay the cost of anyone emergency ambulance Services from a Non–Plan you hire to represent or help you. Provider and you want us to pay for the Services • You have received Services from a Non–Plan Provider that we did not authorize (other than Supporting Documents Emergency Services, Out-of-Area Urgent Care, Post- You can request payment or reimbursement orally or in Stabilization Care, or emergency Ambulance writing. Your request for payment or reimbursement, and Services) and you want us to pay for the Services any related documents that you give us, constitute your • You want to appeal a denial of an initial claim for claim. payment Claim forms for Emergency Services, Post- Please follow the procedures under "Grievances" in the Stabilization Care, Out-of-Area Urgent Care, and "Dispute Resolution" section in the following situations: emergency ambulance Services • You want us to cover Services that you have not yet To file a claim in writing for Emergency Services, Post- received Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services, please use our claim • You want us to continue to cover an ongoing course form. You can obtain a claim form in the following of covered treatment ways: • You want to appeal a written denial of a request for • By visiting our website at kp.org Services that require prior authorization (as described under "Medical Group authorization procedure for • In person from any Member Services office at a Plan certain referrals") Facility and from Plan Providers • By calling our Member Service Contact Center at 1-800-464-4000 or 1-800-390-3510 (TTY users call Who May File 711) The following people may file claims: Claims forms for all other Services • You may file for yourself To file a claim in writing for all other Services, you may • You can ask a friend, relative, attorney, or any other use our Complaint or Benefit Claim/Request form. You individual to file a claim for you by appointing him or can obtain this form in the following ways: her in writing as your authorized representative • By visiting our website at kp.org • A parent may file for his or her child under age 18, • In person from any Member Services office at a Plan except that the child must appoint the parent as Facility and from Plan Providers authorized representative if the child has the legal right to control release of information that is relevant • By calling our Member Service Contact Center at to the claim 1-800-464-4000 (TTY users call 711)

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Other supporting information For Southern California Home Region Members: When you file a claim, please include any information Kaiser Foundation Health Plan, Inc. that clarifies or supports your position. For example, Claims Department if you have paid for Services, please include any bills P.O. Box 7004 and receipts that support your claim. To request that we Downey, CA 90242-7004 pay a Non–Plan Provider for Services, include any bills from the Non–Plan Provider. If the Non–Plan Provider Please call our Member Service Contact Center if you states that they will file the claim, you are still need help filing your claim. responsible for making sure that we receive everything we need to process the request for payment. When Submitting a claim for all other Services appropriate, we will request medical records from Plan If you have received Services from a Non–Plan Provider Providers on your behalf. If you tell us that you have that we did not authorize (other than Emergency consulted with a Non–Plan Provider and are unable to Services, Post-Stabilization Care, Out-of-Area Urgent provide copies of relevant medical records, we will Care, or emergency ambulance Services), then as soon as contact the provider to request a copy of your relevant possible after you receive the Services, you must file medical records. We will ask you to provide us a written your claim in one of the following ways: authorization so that we can request your records. • By delivering your claim to a Member Services office at a Plan Facility (please refer to Your Guidebook for If you want to review the information that we have addresses) collected regarding your claim, you may request, and we will provide without charge, copies of all relevant • By mailing your claim to a Member Services office at documents, records, and other information. You also a Plan Facility (please refer to Your Guidebook for have the right to request any diagnosis and treatment addresses) codes and their meanings that are the subject of your • By calling our Member Service Contact Center at claim. To make a request, you should follow the steps in 1-800-464-4000 (TTY users call 711) the written notice sent to you about your claim. • By visiting our website at kp.org

Initial Claims Please call our Member Service Contact Center if you need help filing your claim. To request that we pay a provider (or reimburse you) for Services that you have already received, you must file a After we receive your claim claim. If you have any questions about the claims We will send you an acknowledgment letter within five process, please call our Member Service Contact Center. days after we receive your claim.

Submitting a claim for Emergency Services, After we review your claim, we will respond as follows: Post-Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services • If we have all the information we need we will send If you have received Emergency Services, Post- you a written decision within 30 days after we receive Stabilization Care, Out-of-Area Urgent Care, or your claim. We may extend the time for making a decision for an additional 15 days if circumstances emergency ambulance Services from a Non–Plan Provider, then as soon as possible after you received the beyond our control delay our decision, if we notify Services, you must file your claim by mailing a you within 30 days after we receive your claim completed claim form and supporting information to the • If we need more information, we will ask you for the following address: information before the end of the initial 30-day decision period. We will send our written decision no For Northern California Home Region Members: later than 15 days after the date we receive the Kaiser Foundation Health Plan, Inc. additional information. If we do not receive the Claims Department necessary information within the timeframe specified P.O. Box 12923 in our letter, we will make our decision based on the Oakland, CA 94604-2923 information we have within 15 days after the end of that timeframe

If we pay any part of your claim, we will subtract applicable Cost Share from any payment we make to you or the Non–Plan Provider. You are not responsible for

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any amounts beyond your Cost Share for covered Additional information regarding a claim for Services Emergency Services. If we deny your claim (if we do not from a Non–Plan Provider that we did not authorize agree to pay for all the Services you requested other than (other than Emergency Services, Post-Stabilization the applicable Cost Share), our letter will explain why Care, Out-of-Area Urgent Care, or emergency we denied your claim and how you can appeal. ambulance Services). If we initially denied your request, you must file your appeal within 180 days after If you later receive any bills from the Non–Plan Provider the date you received our denial letter. You may send us for covered Services (other than bills for your Cost information including comments, documents, and Share), please call our Member Service Contact Center medical records that you believe support your claim. for assistance. If we asked for additional information and you did not provide it before we made our initial decision about your claim, then you may still send us the additional Appeals information so that we may include it as part of our review of your appeal. Please send all additional Claims for Emergency Services, Post-Stabilization information to the address or fax mentioned in your Care, Out-of-Area Urgent Care, or emergency denial letter. ambulance Services from a Non–Plan Provider. If we did not decide fully in your favor and you want to appeal Also, you may give testimony in writing or by telephone. our decision, you may submit your appeal in one of the Please send your written testimony to the address following ways: mentioned in our acknowledgment letter, sent to you • By mailing your appeal to the Claims Department at within five days after we receive your appeal. To arrange the following address: to give testimony by telephone, you should call the Kaiser Foundation Health Plan, Inc. phone number mentioned in our acknowledgment letter. Special Services Unit P.O. Box 23280 We will add the information that you provide through Oakland, CA 94623 testimony or other means to your appeal file and we will • By calling our Member Service Contact Center at review it without regard to whether this information was 1-800-464-4000 (TTY users call 711) filed or considered in our initial decision regarding your request for Services. You have the right to request any • By visiting our website at kp.org diagnosis and treatment codes and their meanings that are the subject of your claim. Claims for Services from a Non–Plan Provider that we did not authorize (other than Emergency Services, We will share any additional information that we collect Post-Stabilization Care, Out-of-Area Urgent Care, or in the course of our review and we will send it to you. emergency ambulance Services). If we did not decide If we believe that your request should not be granted, fully in your favor and you want to appeal our decision, before we issue our final decision letter, we will also you may submit your appeal in one of the following share with you any new or additional reasons for that ways: decision. We will send you a letter explaining the • By visiting our website at kp.org additional information and/or reasons. Our letters about additional information and new or additional rationales • By mailing your appeal to the Member Services will tell you how you can respond to the information Department at a Plan Facility (please refer to Your provided if you choose to do so. If you do not respond Guidebook for addresses) before we must issue our final decision letter, that • In person from any Member Services office at a Plan decision will be based on the information in your appeal Facility and from Plan Providers file. • By calling our Member Service Contact Center at 1-800-464-4000 (TTY users call 711) We will send you a resolution letter within 30 days after we receive your appeal. If we do not decide in your When you file an appeal, please include any information favor, our letter will explain why and describe your that clarifies or supports your position. If you want to further appeal rights. review the information that we have collected regarding your claim, you may request, and we will provide without charge, copies of all relevant documents, External Review records, and other information. To make a request, you You must exhaust our internal claims and appeals should contact or Member Service Contact Center. procedures before you may request external review

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unless we have failed to comply with the claims and • You received a written denial for a second opinion or appeals procedures described in this "Post-Service we did not respond to your request for a second Claims and Appeals" section. For information about opinion in an expeditious manner, as appropriate for external review process, see "Independent Medical your condition Review (IMR)" in the "Dispute Resolution" section. • Your treating physician has said that Services are not Medically Necessary and you want us to cover the Additional Review Services • You were told that Services are not covered and you You may have certain additional rights if you remain believe that the Services should be covered dissatisfied after you have exhausted our internal claims • and appeals procedure, and if applicable, external You want us to continue to cover an ongoing course review: of covered treatment • • If your Group's benefit plan is subject to the You are dissatisfied with how long it took to get Employee Retirement Income Security Act (ERISA), Services, including getting an appointment, in the you may file a civil action under section 502(a) of waiting room, or in the exam room ERISA. To understand these rights, you should check • You want to report unsatisfactory behavior by with your Group or contact the Employee Benefits providers or staff, or dissatisfaction with the Security Administration (part of the U.S. Department condition of a facility of Labor) at ( ) 1-866-444-EBSA 1-866-444-3272 • You believe you have faced discrimination from • If your Group's benefit plan is not subject to ERISA providers, staff, or Health Plan (for example, most state or local government plans • We terminated your membership and you disagree and church plans), you may have a right to request with that termination review in state court Who may file The following people may file a grievance: Dispute Resolution • You may file for yourself • We are committed to providing you with quality care and You can ask a friend, relative, attorney, or any other with a timely response to your concerns. You can discuss individual to file a grievance for you by appointing your concerns with our Member Services representatives him or her in writing as your authorized at most Plan Facilities, or you can call our Member representative Service Contact Center. • A parent may file for his or her child under age 18, except that the child must appoint the parent as authorized representative if the child has the legal Grievances right to control release of information that is relevant to the grievance This "Grievances" section describes our grievance procedure. A grievance is any expression of • A court-appointed guardian may file for his or her dissatisfaction expressed by you or your authorized ward, except that the ward must appoint the court- representative through the grievance process. If you want appointed guardian as authorized representative if the to make a claim for payment or reimbursement for ward has the legal right to control release of Services that you have already received from a Non–Plan information that is relevant to the grievance Provider, please follow the procedure in the "Post- • A court-appointed conservator may file for his or her Service Claims and Appeals" section. conservatee • An agent under a currently effective health care Here are some examples of reasons you might file a proxy, to the extent provided under state law, may file grievance: for his or her principal • You are not satisfied with the quality of care you • Your physician may act as your authorized received representative with your verbal consent to request an • You received a written denial of Services that require urgent grievance as described under "Urgent prior authorization from the Medical Group and you procedure" in this "Grievances" section want us to cover the Services

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Authorized representatives must be appointed in writing Prescription Drug Requests" in this "Dispute Resolution" using either our authorization form or some other form of section. written notification. The authorization form is available from the Member Services Department at a Plan Facility, For all other grievances, we will send you an on our website at kp.org, or by calling our Member acknowledgment letter within five days after we receive Service Contact Center. Your written authorization must your grievance. We will send you a resolution letter accompany the grievance. You must pay the cost of within 30 days after we receive your grievance. If you anyone you hire to represent or help you. are requesting Services, and we do not decide in your favor, our letter will explain why and describe your How to file further appeal rights. You can file a grievance orally or in writing. Your grievance must explain your issue, such as the reasons If you want to review the information that we have why you believe a decision was in error or why you are collected regarding your grievance, you may request, and dissatisfied with the Services you received. we will provide without charge, copies of all relevant documents, records, and other information. To make a To file a grievance in writing, please use our Complaint request, you should contact our Member Service Contact or Benefit Claim/Request form. You can obtain the form Center. in the following ways: • By visiting our website at kp.org Urgent procedure. If you want us to consider your grievance on an urgent basis, please tell us that when you • In person from any Member Services office at a Plan file your grievance. Facility and from Plan Providers • By calling our Member Service Contact Center toll You must file your urgent grievance in one of the free at 1-800-464-4000 (TTY users call 711) following ways: • By calling our Expedited Review Unit toll free at You must file your grievance within 180 days following 1-888-987-7247 (TTY users call 711) the incident or action that is subject to your • dissatisfaction. You may send us information including By mailing a written request to: comments, documents, and medical records that you Kaiser Foundation Health Plan, Inc. believe support your grievance. Expedited Review Unit P.O. Box 23170 Standard procedure. You must file your grievance in Oakland, CA 94623-0170 one of the following ways: • By faxing a written request to our Expedited Review • By completing a Complaint or Benefit Claim/Request Unit toll free at 1-888-987-2252 form at a Member Services office at a Plan Facility • By visiting a Member Services office at a Plan (please refer to Your Guidebook for addresses) Facility (please refer to Your Guidebook for • By mailing your grievance to a Member Services addresses) office at a Plan Facility (please refer to Your • By completing the grievance form on our website at Guidebook for addresses) kp.org • By calling our Member Service Contact Center toll free at 1-800-464-4000 (TTY users call 711) We will decide whether your grievance is urgent or non- urgent unless your attending health care provider tells us • By completing the grievance form on our website at your grievance is urgent. If we determine that your kp.org grievance is not urgent, we will use the procedure described under "Standard procedure" in this Please call our Member Service Contact Center if you "Grievances" section. Generally, a grievance is urgent need help filing a grievance. only if one of the following is true: • Using the standard procedure could seriously If your grievance involves a request to obtain a jeopardize your life, health, or ability to regain nonformulary prescription drug, we will notify you of maximum function our decision within 72 hours. If we do not decide in your favor, our letter will explain why and describe your • Using the standard procedure would, in the opinion of further appeal rights. For information on how to request a physician with knowledge of your medical a review by an independent review organization, see condition, subject you to severe pain that cannot be "Independent Review Organization for Nonformulary

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adequately managed without extending your course If we believe that your request should not be granted, of covered treatment before we issue our decision letter, we will also share • A physician with knowledge of your medical with you any new or additional reasons for that decision. condition determines that your grievance is urgent We will send you a letter explaining the additional information and/or reasons. Our letters about additional information and new or additional rationales will tell you If your grievance involves a request to obtain a how you can respond to the information provided if you nonformulary prescription drug and we respond to your choose to do so. If your grievance is urgent, the request on an urgent basis, we will notify you of our information will be provided to you orally and followed decision within 24 hours of your request. If we do not in writing. If you do not respond before we must issue decide in your favor, our letter will explain why and our final decision letter, that decision will be based on describe your further appeal rights. For information on the information in your grievance file. how to request a review by an independent review organization, see "Independent Review Organization for Nonformulary Prescription Drug Requests" in this Additional information regarding appeals of written "Dispute Resolution" section. denials for Services that require prior authorization. You must file your appeal within 180 days after the date you received our denial letter. For all other grievances that we respond to on an urgent basis, we will give you oral notice of our decision as soon as your clinical condition requires, but not later You have the right to request any diagnosis and than 72 hours after we received your grievance. We will treatment codes and their meanings that are the subject of send you a written confirmation of our decision within 3 your appeal. days after we received your grievance. Also, you may give testimony in writing or by telephone. If we do not decide in your favor, our letter will explain Please send your written testimony to the address why and describe your further appeal rights. mentioned in our acknowledgment letter. To arrange to give testimony by telephone, you should call the phone number mentioned in our acknowledgment letter. Note: If you have an issue that involves an imminent and serious threat to your health (such as severe pain or potential loss of life, limb, or major bodily function), you We will add the information that you provide through can contact the California Department of Managed testimony or other means to your appeal file and we will Health Care at any time at 1-888-HMO-2219 (TDD consider it in our decision regarding your appeal. 1-877-688-9891) without first filing a grievance with us. We will share any additional information that we collect If you want to review the information that we have in the course of our review and we will send it to you. collected regarding your grievance, you may request, and If we believe that your request should not be granted, we will provide without charge, copies of all relevant before we issue our decision letter, we will also share documents, records, and other information. To make a with you any new or additional reasons for that decision. request, you should contact our Member Service Contact We will send you a letter explaining the additional Center. information and/or reasons. Our letters about additional information and new or additional rationales will tell you how you can respond to the information provided if you Additional information regarding pre-service choose to do so. If your appeal is urgent, the information requests for Medically Necessary Services. You may will be provided to you orally and followed in writing. give testimony in writing or by telephone. Please send If you do not respond before we must issue our final your written testimony to the address mentioned in our decision letter, that decision will be based on the acknowledgment letter. To arrange to give testimony by information in your appeal file. telephone, you should call the phone number mentioned in our acknowledgment letter. Independent Review Organization for We will add the information that you provide through testimony or other means to your grievance file and we Nonformulary Prescription Drug will consider it in our decision regarding your pre- Requests service request for Medically Necessary Services. If you filed a grievance to obtain a nonformulary prescription drug and we did not decide in your favor, We will share any additional information that we collect you may submit a request for a review of your grievance in the course of our review and we will send it to you. by an independent review organization ("IRO"). You

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must submit your request for IRO review within 180 health plan related to the medical necessity of a proposed days of the receipt of our decision letter. service or treatment, coverage decisions for treatments that are experimental or investigational in nature and You must file your request for IRO review in one of the payment disputes for emergency or urgent medical following ways: services. The department also has a toll-free telephone • By calling our Expedited Review Unit toll free at number (1-888-HMO-2219) and a TDD line 1-888-987-7247 (TTY users call 711) (1-877-688-9891) for the hearing and speech impaired. The department's Internet website • By mailing a written request to: Kaiser Foundation Health Plan, Inc. http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. Expedited Review Unit P.O. Box 23170 Oakland, CA 94623-0170 Independent Medical Review (IMR) • By faxing a written request to our Expedited Review Unit toll free at 1-888-987-2252 Except as described in this "Independent Medical Review (IMR)" section, you must exhaust our internal • By visiting a Member Services office at a Plan grievance procedure before you may request independent Facility (please refer to Your Guidebook for medical review unless we have failed to comply with the addresses) grievance procedure described under "Grievances" in this • By completing the grievance form on our website at "Dispute Resolution" section. If you qualify, you or your kp.org authorized representative may have your issue reviewed through the IMR process managed by the California For urgent IRO reviews, we will forward to you the Department of Managed Health Care (DMHC). The independent reviewer's decision within 24 hours. For DMHC determines which cases qualify for IMR. This non-urgent requests, we will forward the independent review is at no cost to you. If you decide not to request reviewer's decision to you within 72 hours. If the an IMR, you may give up the right to pursue some legal independent reviewer does not decide in your favor, you actions against us. may submit a complaint to the Department of Managed Health Care, as described under "Department of You may qualify for IMR if all of the following are true: Managed Health Care Complaints" in this "Dispute • One of these situations applies to you: Resolution" section. You may also submit a request for ♦ you have a recommendation from a provider an Independent Medical Review as described under requesting Medically Necessary Services "Independent Medical Review" in this "Dispute Resolution" section. ♦ you have received Emergency Services, emergency ambulance Services, or Urgent Care from a provider who determined the Services to be Department of Managed Health Care Medically Necessary Complaints ♦ you have been seen by a Plan Provider for the diagnosis or treatment of your medical condition The California Department of Managed Health Care • Your request for payment or Services has been is responsible for regulating health care service plans. denied, modified, or delayed based in whole or in part If you have a grievance against your health plan, you on a decision that the Services are not Medically should first telephone your health plan toll free at Necessary 1-800-464-4000 (TTY users call 711) and use your health plan's grievance process before contacting the • You have filed a grievance and we have denied it or department. Utilizing this grievance procedure does not we haven't made a decision about your grievance prohibit any potential legal rights or remedies that may within 30 days (or three days for urgent grievances). be available to you. If you need help with a grievance The DMHC may waive the requirement that you first involving an emergency, a grievance that has not been file a grievance with us in extraordinary and satisfactorily resolved by your health plan, or a grievance compelling cases, such as severe pain or potential loss that has remained unresolved for more than 30 days, you of life, limb, or major bodily function. If we have may call the department for assistance. You may also be denied your grievance, you must submit your request eligible for an Independent Medical Review (IMR). for an IMR within six months of the date of our If you are eligible for IMR, the IMR process will provide written denial. However, the DMHC may accept your an impartial review of medical decisions made by a request after six months if they determine that circumstances prevented timely submission

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You may also qualify for IMR if the Service you We do not cover the Services of the Non–Plan requested has been denied on the basis that it is Provider experimental or investigational as described under "Experimental or investigational denials." Note: You can request IMR for experimental or investigational denials at any time without first filing a If the DMHC determines that your case is eligible for grievance with us. IMR, it will ask us to send your case to the DMHC's IMR organization. The DMHC will promptly notify you of its decision after it receives the IMR organization's Office of Civil Rights Complaints determination. If the decision is in your favor, we will contact you to arrange for the Service or payment. If you believe that you have been discriminated against by a Plan Provider or by us because of your race, color, national origin, disability, age, sex (including sex Experimental or investigational denials stereotyping and gender identity), or religion, you may If we deny a Service because it is experimental or file a complaint with the Office of Civil Rights in the investigational, we will send you our written explanation United States Department of Health and Human Services within three days after we received your request. We will ("OCR"). explain why we denied the Service and provide additional dispute resolution options. Also, we will You may file your complaint with the OCR within 180 provide information about your right to request days of when you believe the act of discrimination Independent Medical Review if we had the following occurred. However, the OCR may accept your request information when we made our decision: after six months if they determine that circumstances • Your treating physician provided us a written prevented timely submission. For more information on statement that you have a life-threatening or seriously the OCR and how to file a complaint with the OCR, go debilitating condition and that standard therapies have to hhs.gov/civil-rights. not been effective in improving your condition, or that standard therapies would not be appropriate, or that there is no more beneficial standard therapy we Additional Review cover than the therapy being requested. "Life- threatening" means diseases or conditions where the You may have certain additional rights if you remain likelihood of death is high unless the course of the dissatisfied after you have exhausted our internal claims disease is interrupted, or diseases or conditions with and appeals procedure, and if applicable, external potentially fatal outcomes where the end point of review: clinical intervention is survival. "Seriously • If your Group's benefit plan is subject to the debilitating" means diseases or conditions that cause Employee Retirement Income Security Act (ERISA), major irreversible morbidity you may file a civil action under section 502(a) of • If your treating physician is a Plan Physician, he or ERISA. To understand these rights, you should check she recommended a treatment, drug, device, with your Group or contact the Employee Benefits procedure, or other therapy and certified that the Security Administration (part of the U.S. Department requested therapy is likely to be more beneficial to of Labor) at 1-866-444-EBSA (1-866-444-3272) you than any available standard therapies and • If your Group's benefit plan is not subject to ERISA included a statement of the evidence relied upon by (for example, most state or local government plans the Plan Physician in certifying his or her and church plans), you may have a right to request recommendation review in state court • You (or your Non–Plan Physician who is a licensed, and either a board-certified or board-eligible, physician qualified in the area of practice appropriate Binding Arbitration to treat your condition) requested a therapy that, For all claims subject to this "Binding Arbitration" based on two documents from the medical and section, both Claimants and Respondents give up the scientific evidence, as defined in California Health right to a jury or court trial and accept the use of binding and Safety Code Section 1370.4(d), is likely to be arbitration. Insofar as this "Binding Arbitration" section more beneficial for you than any available standard applies to claims asserted by Kaiser Permanente Parties, therapy. The physician's certification included a it shall apply retroactively to all unresolved claims that statement of the evidence relied upon by the accrued before the effective date of this EOC. Such physician in certifying his or her recommendation.

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retroactive application shall be binding only on the • The Permanente Federation, LLC Kaiser Permanente Parties. • The Permanente Company, LLC Scope of arbitration • Any Southern California Permanente Medical Group Any dispute shall be submitted to binding arbitration or The Permanente Medical Group physician if all of the following requirements are met: • Any individual or organization whose contract with • The claim arises from or is related to an alleged any of the organizations identified above requires violation of any duty incident to or arising out of or arbitration of claims brought by one or more Member relating to this EOC or a Member Party's relationship Parties to Kaiser Foundation Health Plan, Inc. (Health Plan), • Any employee or agent of any of the foregoing including any claim for medical or hospital malpractice (a claim that medical services or items "Claimant" refers to a Member Party or a Kaiser were unnecessary or unauthorized or were Permanente Party who asserts a claim as described improperly, negligently, or incompetently rendered), above. "Respondent" refers to a Member Party or a for premises liability, or relating to the coverage for, Kaiser Permanente Party against whom a claim is or delivery of, services or items, irrespective of the asserted. legal theories upon which the claim is asserted • The claim is asserted by one or more Member Parties Rules of Procedure against one or more Kaiser Permanente Parties or by Arbitrations shall be conducted according to the Rules one or more Kaiser Permanente Parties against one or for Kaiser Permanente Member Arbitrations Overseen more Member Parties by the Office of the Independent Administrator ("Rules of Procedure") developed by the Office of the Independent • Governing law does not prevent the use of binding Administrator in consultation with Kaiser Permanente arbitration to resolve the claim and the Arbitration Oversight Board. Copies of the Rules of Procedure may be obtained from our Member Service Members enrolled under this EOC thus give up their Contact Center. right to a court or jury trial, and instead accept the use of binding arbitration except that the following types of Initiating arbitration claims are not subject to binding arbitration: Claimants shall initiate arbitration by serving a Demand • Claims within the jurisdiction of the Small Claims for Arbitration. The Demand for Arbitration shall include Court the basis of the claim against the Respondents; the • Claims subject to a Medicare appeal procedure as amount of damages the Claimants seek in the arbitration; applicable to Kaiser Permanente Senior Advantage the names, addresses, and telephone numbers of the Members Claimants and their attorney, if any; and the names of all Respondents. Claimants shall include in the Demand for • Claims that cannot be subject to binding arbitration Arbitration all claims against Respondents that are based under governing law on the same incident, transaction, or related circumstances. As referred to in this "Binding Arbitration" section, "Member Parties" include: Serving Demand for Arbitration • A Member Health Plan, Kaiser Foundation Hospitals, KP Cal, LLC, • A Member's heir, relative, or personal representative The Permanente Medical Group, Inc., Southern California Permanente Medical Group, The Permanente • Any person claiming that a duty to him or her arises Federation, LLC, and The Permanente Company, LLC, from a Member's relationship to one or more Kaiser shall be served with a Demand for Arbitration by mailing Permanente Parties the Demand for Arbitration addressed to that Respondent in care of: "Kaiser Permanente Parties" include: • Kaiser Foundation Health Plan, Inc. • Kaiser Foundation Hospitals • KP Cal, LLC • The Permanente Medical Group, Inc. • Southern California Permanente Medical Group

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For Northern California Home Region Members: Payment of arbitrators' fees and expenses Kaiser Foundation Health Plan, Inc. Health Plan will pay the fees and expenses of the neutral Legal Department arbitrator under certain conditions as set forth in the 1950 Franklin St., 17th Floor Rules of Procedure. In all other arbitrations, the fees and Oakland, CA 94612 expenses of the neutral arbitrator shall be paid one-half For Southern California Home Region Members: by the Claimants and one-half by the Respondents. Kaiser Foundation Health Plan, Inc. If the parties select party arbitrators, Claimants shall be Legal Department responsible for paying the fees and expenses of their 393 E. Walnut St. Pasadena, CA 91188 party arbitrator and Respondents shall be responsible for paying the fees and expenses of their party arbitrator. Service on that Respondent shall be deemed completed Costs when received. All other Respondents, including individuals, must be served as required by the California Except for the aforementioned fees and expenses of the Code of Civil Procedure for a civil action. neutral arbitrator, and except as otherwise mandated by laws that apply to arbitrations under this "Binding Filing fee Arbitration" section, each party shall bear the party's own attorneys' fees, witness fees, and other expenses incurred The Claimants shall pay a single, nonrefundable filing in prosecuting or defending against a claim regardless of fee of $150 per arbitration payable to "Arbitration the nature of the claim or outcome of the arbitration. Account" regardless of the number of claims asserted in the Demand for Arbitration or the number of Claimants General provisions or Respondents named in the Demand for Arbitration. A claim shall be waived and forever barred if (1) on the Any Claimant who claims extreme hardship may request date the Demand for Arbitration of the claim is served, that the Office of the Independent Administrator waive the claim, if asserted in a civil action, would be barred as the filing fee and the neutral arbitrator's fees and to the Respondent served by the applicable statute of expenses. A Claimant who seeks such waivers shall limitations, (2) Claimants fail to pursue the arbitration complete the Fee Waiver Form and submit it to the claim in accord with the Rules of Procedure with Office of the Independent Administrator and reasonable diligence, or (3) the arbitration hearing is not simultaneously serve it upon the Respondents. The Fee commenced within five years after the earlier of (a) the Waiver Form sets forth the criteria for waiving fees and date the Demand for Arbitration was served in accord is available by calling our Member Service Contact with the procedures prescribed herein, or (b) the date of Center. filing of a civil action based upon the same incident, transaction, or related circumstances involved in the claim. A claim may be dismissed on other grounds by the Number of arbitrators neutral arbitrator based on a showing of a good cause. The number of arbitrators may affect the Claimants' If a party fails to attend the arbitration hearing after responsibility for paying the neutral arbitrator's fees and being given due notice thereof, the neutral arbitrator may expenses (see the Rules of Procedure). proceed to determine the controversy in the party's absence. If the Demand for Arbitration seeks total damages of $200,000 or less, the dispute shall be heard and The California Medical Injury Compensation Reform determined by one neutral arbitrator, unless the parties Act of 1975 (including any amendments thereto), otherwise agree in writing that the arbitration shall be including sections establishing the right to introduce heard by two party arbitrators and one neutral arbitrator. evidence of any insurance or disability benefit payment The neutral arbitrator shall not have authority to award to the patient, the limitation on recovery for non- monetary damages that are greater than $200,000. economic losses, and the right to have an award for future damages conformed to periodic payments, shall If the Demand for Arbitration seeks total damages of apply to any claims for professional negligence or any more than $200,000, the dispute shall be heard and other claims as permitted or required by law. determined by one neutral arbitrator and two party arbitrators, one jointly appointed by all Claimants and Arbitrations shall be governed by this "Binding one jointly appointed by all Respondents. Parties who are Arbitration" section, Section 2 of the Federal Arbitration entitled to select a party arbitrator may agree to waive Act, and the California Code of Civil Procedure this right. If all parties agree, these arbitrations will be provisions relating to arbitration that are in effect at the heard by a single neutral arbitrator.

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time the statute is applied, together with the Rules of Termination for Cause Procedure, to the extent not inconsistent with this "Binding Arbitration" section. In accord with the rule If you intentionally commit fraud in connection with that applies under Sections 3 and 4 of the Federal membership, Health Plan, or a Plan Provider, we may Arbitration Act, the right to arbitration under this terminate your membership by sending written notice to "Binding Arbitration" section shall not be denied, stayed, the Subscriber; termination will be effective 30 days or otherwise impeded because a dispute between a from the date we send the notice. Some examples of Member Party and a Kaiser Permanente Party involves fraud include: both arbitrable and nonarbitrable claims or because one • Misrepresenting eligibility information about you or a or more parties to the arbitration is also a party to a Dependent pending court action with a third party that arises out of the same or related transactions and presents a possibility • Presenting an invalid prescription or physician order of conflicting rulings or findings. • Misusing a Kaiser Permanente ID card (or letting someone else use it) • Giving us incorrect or incomplete material Termination of Membership information. For example, you have entered into a Surrogacy Arrangement and you fail to send us the Your Group is required to inform the Subscriber of the information we require under "Surrogacy date your membership terminates. Your membership arrangements" under "Reductions" in the "Exclusions, termination date is the first day you are not covered (for Limitations, Coordination of Benefits, and example, if your termination date is January 1, 2019, Reductions" section your last minute of coverage was at 11:59 p.m. on • Failing to notify us of changes in family status or December 31, 2018). When a Subscriber's membership Medicare coverage that may affect your eligibility or ends, the memberships of any Dependents end at the benefits same time. You will be billed as a non-Member for any Services you receive after your membership terminates. If we terminate your membership for cause, you will not Health Plan and Plan Providers have no further liability be allowed to enroll in Health Plan in the future. We may or responsibility under this EOC after your membership also report criminal fraud and other illegal acts to the terminates, except as provided under "Payments after authorities for prosecution. Termination" in this "Termination of Membership" section. Termination of a Product or all Products Termination Due to Loss of Eligibility We may terminate a particular product or all products offered in the group market as permitted or required by If you no longer meet the eligibility requirements law. If we discontinue offering a particular product in the described under "Who Is Eligible" in the "Premiums, group market, we will terminate just the particular Eligibility, and Enrollment" section, your Group will product by sending you written notice at least 90 days notify you of the date that your membership will end. before the product terminates. If we discontinue offering Your membership termination date is the first day you all products in the group market, we may terminate your are not covered. For example, if your termination date is Group's Agreement by sending you written notice at least January 1, 2019, your last minute of coverage was at 180 days before the Agreement terminates. 11:59 p.m. on December 31, 2018.

Payments after Termination Termination of Agreement If we terminate your membership for cause or for If your Group's Agreement with us terminates for any nonpayment, we will: reason, your membership ends on the same date. Your • Group is required to notify Subscribers in writing if its Refund any amounts we owe your Group for Agreement with us terminates. Premiums paid after the termination date • Pay you any amounts we have determined that we owe you for claims during your membership in accord with the "Emergency Services and Urgent Care" and "Dispute Resolution" sections

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We will deduct any amounts you owe Health Plan or COBRA" in this "Continuation of Group Coverage" Plan Providers from any payment we make to you. section.

Cal-COBRA State Review of Membership If you are eligible for Cal-COBRA, you can continue Termination coverage as described in this "Cal-COBRA" section if you apply for coverage in compliance with Cal- If you believe that we terminated your membership COBRA law and pay applicable Premiums. because of your ill health or your need for care, you may request a review of the termination by the California Eligibility and effective date of coverage for Cal- Department of Managed Health Care (please see COBRA after COBRA. If your group is subject to "Department of Managed Health Care Complaints" in the COBRA and your COBRA coverage ends, you may be "Dispute Resolution" section). able to continue Group coverage effective the date your COBRA coverage ends if all of the following are true: • Your effective date of COBRA coverage was on or Continuation of Membership after January 1, 2003 • You have exhausted the time limit for COBRA If your membership under this EOC ends, you may be coverage and that time limit was 18 or 29 months eligible to continue Health Plan membership without a break in coverage. You may be able to continue Group • You do not have Medicare coverage under this EOC as described under "Continuation of Group Coverage." Also, you may be You must request an enrollment application by calling able to continue membership under an individual plan as our Member Service Contact Center within 60 days of described under "Continuation of Coverage under an the date of when your COBRA coverage ends. Individual Plan." If at any time you become entitled to continuation of Group coverage, please examine your Eligibility and effective date of coverage for Cal- coverage options carefully before declining this COBRA when your coverage is through a small coverage. Individual plan premiums and coverage will be employer. If your group is not subject to COBRA, you different from the premiums and coverage under your may be able to continue uninterrupted Group coverage Group plan. under this EOC if all of the following are true: • Your employer meets the definition of "small Continuation of Group Coverage employer" in Section 1357 of the California Health and Safety Code COBRA • Your employer employed between 2 to 19 eligible You may be able to continue your coverage under this employees on at least 50 percent of its working days EOC for a limited time after you would otherwise lose during the last calendar year eligibility, if required by the federal COBRA law (the • You do not have Medicare Part A Consolidated Omnibus Budget Reconciliation Act). COBRA applies to most employees (and most of their • You experience one of the following qualifying covered family Dependents) of most employers with 20 events: or more employees. ♦ your coverage is through a Subscriber who dies, divorces, legally separates, or gets Medicare If your Group is subject to COBRA and you are eligible ♦ you no longer qualify as a Dependent, under the for COBRA coverage, in order to enroll you must submit terms of the "Who Is Eligible" section of this EOC a COBRA election form to your Group within the ♦ COBRA election period. Please ask your Group for you are a Subscriber, or your coverage is through a details about COBRA coverage, such as how to elect Subscriber, whose employment terminates (other coverage, how much you must pay for coverage, when than for gross misconduct) or whose hours of coverage and Premiums may change, and where to send employment are reduced your Premium payments. You must request an enrollment application by calling If you enroll in COBRA and exhaust the time limit for our Member Service Contact Center within 60 days of COBRA coverage, you may be able to continue Group the date of a qualifying event described above. coverage under state law as described under "Cal-

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Cal-COBRA enrollment and Premiums. Within 10 Cal-COBRA. Please ask your Group for information days of your request for an enrollment application, we about health plans available to you either at open will send you our application, which will include enrollment or if your Group terminates a health plan's Premium and billing information. You must return your agreement. completed application within 63 days of the date of our termination letter or of your membership termination In order for you to switch from another health plan and date (whichever date is later). continue your Cal-COBRA coverage with us, we must receive your enrollment application during your Group's If we approve your enrollment application, we will send open enrollment period, or within 63 days of receiving you billing information within 30 days after we receive the Group's termination notice described under "Group your application. You must pay the bill within 45 days responsibilities." To request an application, please call after the date we issue the bill. The first Premium our Member Service Contact Center. We will send you payment will include coverage from your Cal-COBRA our enrollment application and you must return your effective date through our current billing cycle. You completed application before open enrollment ends or must send us the Premium payment by the due date on within 63 days of receiving the termination notice the bill to be enrolled in Cal-COBRA. described under "Group responsibilities." If we approve your enrollment application, we will send you billing After that first payment, your Premium payment for the information within 30 days after we receive your upcoming coverage month is due on first day of that application. You must pay the bill within 45 days after month. The Premiums will not exceed 110 percent of the the date we issue the bill. You must send us the Premium applicable Premiums charged to a similarly situated payment by the due date on the bill to be enrolled in Cal- individual under the Group benefit plan except that COBRA. Premiums for disabled individuals after 18 months of COBRA coverage will not exceed 150 percent instead of How you may terminate your Cal-COBRA coverage. 110 percent. Returned checks or insufficient funds on You may terminate your Cal-COBRA coverage by electronic payments will be subject to a $25 fee. sending written notice, signed by the Subscriber, to the address below. Your membership will terminate at 11:59 Changes to Cal-COBRA coverage and Premiums. p.m. on the last day of the month in which we receive Your Cal-COBRA coverage is the same as for any your notice. Also, you must include with your notice all similarly situated individual under your Group's amounts payable related to your Cal-COBRA coverage, Agreement, and your Cal-COBRA coverage and including Premiums, for the period prior to your Premiums will change at the same time that coverage or termination date. Premiums change in your Group's Agreement. Your Group's coverage and Premiums will change on the Kaiser Foundation Health Plan, Inc. renewal date of its Agreement (January 1), and may also California Service Center change at other times if your Group's Agreement is P.O. Box 23127 amended. Your monthly invoice will reflect the current San Diego, CA 92193-3127 Premiums that are due for Cal-COBRA coverage, including any changes. For example, if your Group Termination for nonpayment of Cal-COBRA makes a change that affects Premiums retroactively, the Premiums. If you do not pay your required Premiums by amount we bill you will be adjusted to reflect the the due date, we may terminate your membership as retroactive adjustment in Premiums. Your Group can tell described in this "Termination for nonpayment of Cal- you whether this EOC is still in effect and give you a COBRA Premiums" section. If you intend to terminate current one if this EOC has expired or been amended. your membership, be sure to notify us as described under You can also request one from our Member Service "How you may terminate your Cal-COBRA coverage" in Contact Center. this "Cal-COBRA" section, as you will be responsible for any Premiums billed to you unless you let us know Cal-COBRA open enrollment or termination of before the first of the coverage month that you want us to another health plan. If you previously elected Cal- terminate your coverage. COBRA coverage through another health plan available through your Group, you may be eligible to enroll in Your Premium payment for the upcoming coverage Kaiser Permanente during your Group's annual open month is due on the first day of that month. If we do not enrollment period, or if your Group terminates its receive full Premium payment on or before the first day agreement with the health plan you are enrolled in. You of the coverage month, we will send a notice of will be entitled to Cal-COBRA coverage only for the nonreceipt of payment (a "Late Notice") to the remainder, if any, of the coverage period prescribed by

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Subscriber's address of record. This Late Notice will monthly Premiums to us at the time we specify, and include the following information: terminates on the earliest of: • A statement that we have not received full Premium • The date your Group's Agreement with us terminates payment and that we will terminate the memberships (you may still be eligible for Cal-COBRA through of everyone in your Family for nonpayment if we do another Group health plan) not receive the required Premiums within 30 days • The date you get Medicare after the date of the Late Notice • The date your coverage begins under any other group • The amount of Premiums that are due health plan that does not contain any exclusion or • The specific date and time when the memberships of limitation with respect to any pre-existing condition everyone in your Family will end if we do not receive you may have (or that does contain such an exclusion the Premiums or limitation, but it has been satisfied) • The date you become covered, or could have become If we terminate your Cal-COBRA coverage because we covered, under COBRA did not receive the required Premiums when due, your membership will end at 11:59 p.m. on the 30th day after • Either the date that is 36 months after the date of your the date of the Late Notice. Your coverage will continue original Cal-COBRA qualifying event or the date that during this 30-day grace period, but upon termination is 36 months after the date of your original COBRA you will be responsible for paying all past due effective date (under this or any other plan) if you Premiums, including the Premiums for this grace period. were enrolled in COBRA before Cal-COBRA • The date your membership is terminated for We will mail a Termination Notice to the Subscriber's nonpayment of Premiums as described under address of record if we do not receive full Premium "Termination for nonpayment of Cal-COBRA payment within 30 days after the date of the Late Notice. Premiums" in this "Continuation of Membership" The Termination Notice will include the following section information: • A statement that we have terminated the memberships Note: If the Social Security Administration determined of everyone in your Family for nonpayment of that you were disabled at any time during the first 60 Premiums days of COBRA coverage, you must notify your Group within 60 days of receiving the determination from • The specific date and time when the memberships of Social Security. Also, if Social Security issues a final everyone in your Family ended determination that you are no longer disabled in the 35th • The amount of Premiums that are due or 36th month of Group continuation coverage, your Cal- COBRA coverage will end the later of: (1) expiration of • Information explaining whether or not you can 36 months after your original COBRA effective date, or reinstate your memberships (2) the first day of the first month following 31 days after • Your appeal rights Social Security issued its final determination. You must notify us within 30 days after you receive Social If we terminate your membership, you are still Security's final determination that you are no longer responsible for paying all amounts due. disabled.

Reinstatement of your membership after termination Group responsibilities. Your Group is required to give for nonpayment of Cal-COBRA Premiums. If we Health Plan written notice within 30 days after a terminate your membership for nonpayment of Subscriber is no longer eligible for coverage due to Premiums, we will permit reinstatement of your termination of employment or reduction of hours. If your membership three times during any 12-month period Group prefers that we not offer Cal-COBRA coverage if we receive the amounts owed within 15 days of the because your Group terminated a Subscriber's date of the Termination Notice. We will not reinstate employment for gross misconduct, your Group must your membership if you do not obtain reinstatement of send written notice within five days after the Subscriber's your terminated membership within the required 15 days, employment terminates to: or if we terminate your membership for nonpayment of Premiums more than three times in a 12-month period.

Termination of Cal-COBRA coverage. Cal-COBRA coverage continues only upon payment of applicable

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Kaiser Foundation Health Plan • Your Group's Agreement with us is replaced by California Service Center another group health plan without limitation as to the P.O. Box 23059 disabling condition San Diego, CA 92193-3059 Your coverage will be subject to the terms of this EOC, Your Group is required to notify us in writing within 30 including Cost Share, but we will not cover Services for days if your Group becomes subject to COBRA under any condition other than your totally disabling condition. federal law. For Subscribers and adult Dependents, "Totally If your Group's agreement with a health plan is Disabled" means that, in the judgment of a Medical terminated, your Group is required to provide written Group physician, an illness or injury is expected to result notice at least 30 days before the termination date to the in death or has lasted or is expected to last for a persons whose Cal-COBRA coverage is terminating. continuous period of at least 12 months, and makes the This notice must inform Cal-COBRA beneficiaries that person unable to engage in any employment or they can continue Cal-COBRA coverage by enrolling in occupation, even with training, education, and any health benefit plan offered by your Group. It must experience. also include information about benefits, premiums, payment instructions, and enrollment forms (including For Dependent children, "Totally Disabled" means that, instructions on how to continue Cal-COBRA coverage in the judgment of a Medical Group physician, an illness under the new health plan). Your Group is required to or injury is expected to result in death or has lasted or is send this information to the person's last known address, expected to last for a continuous period of at least 12 as provided by the prior health plan. Health Plan is not months and the illness or injury makes the child unable obligated to provide this information to qualified to substantially engage in any of the normal activities of beneficiaries if your Group fails to provide the notice. children in good health of like age. These persons will be entitled to Cal-COBRA coverage only for the remainder, if any, of the coverage period To request continuation of coverage for your disabling prescribed by Cal-COBRA. condition, you must call our Member Service Contact Center within 30 days after your Group's Agreement with us terminates. Uniformed Services Employment and Reemployment Rights Act (USERRA) Continuation of Coverage under an If you are called to active duty in the uniformed services, Individual Plan you may be able to continue your coverage under this EOC for a limited time after you would otherwise lose If you want to remain a Health Plan member when your eligibility, if required by the federal USERRA law. You Group coverage ends, you might be able to enroll in one must submit a USERRA election form to your Group of our Kaiser Permanente for Individuals and Families within 60 days after your call to active duty. Please plans. The premiums and coverage under our individual contact your Group to find out how to elect USERRA plan coverage are different from those under this EOC. coverage and how much you must pay your Group. If you want your individual plan coverage to be effective when your Group coverage ends, you must submit your Coverage for a Disabling Condition application within the special enrollment period for If you became Totally Disabled while you were a enrolling in an individual plan due to loss of other Member under your Group's Agreement with us and coverage. Otherwise, you will have to wait until the next while the Subscriber was employed by your Group, and annual open enrollment period. your Group's Agreement with us terminates and is not renewed, we will cover Services for your totally To request an application to enroll directly with us, disabling condition until the earliest of the following please go to kp.org or call our Member Service Contact events occurs: Center. For information about plans that are available through Covered California, see "Covered California" • 12 months have elapsed since your Group's below. Agreement with us terminated • You are no longer Totally Disabled

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Covered California Amendment of Agreement U.S. citizens or legal residents of the U.S. can buy health care coverage from Covered California. This is Your Group's Agreement with us will change California's health insurance marketplace (the periodically. If these changes affect this EOC, your Exchange). You may apply for help to pay for premiums Group is required to inform you in accord with and copayments but only if you buy coverage through applicable law and your Group's Agreement. Covered California. This financial assistance may be available if you meet certain income guidelines. To learn more about coverage that is available through Covered Applications and Statements California, visit CoveredCA.com or call Covered You must complete any applications, forms, or California at 1-800-300-1506 (TTY users call 711). statements that we request in our normal course of business or as specified in this EOC.

Miscellaneous Provisions Assignment

You may not assign this EOC or any of the rights, Administration of Agreement interests, claims for money due, benefits, or obligations We may adopt reasonable policies, procedures, and hereunder without our prior written consent. interpretations to promote orderly and efficient administration of your Group's Agreement, including this EOC. Attorney and Advocate Fees and Expenses

Advance Directives In any dispute between a Member and Health Plan, the Medical Group, or Kaiser Foundation Hospitals, each The California Health Care Decision Law offers several party will bear its own fees and expenses, including ways for you to control the kind of health care you will attorneys' fees, advocates' fees, and other expenses. receive if you become very ill or unconscious, including the following: Claims Review Authority • A Power of Attorney for Health Care lets you name someone to make health care decisions for you when We are responsible for determining whether you are you cannot speak for yourself. It also lets you write entitled to benefits under this EOC and we have the down your own views on life support and other discretionary authority to review and evaluate claims that treatments arise under this EOC. We conduct this evaluation • Individual health care instructions let you express independently by interpreting the provisions of this EOC. your wishes about receiving life support and other We may use medical experts to help us review claims. treatment. You can express these wishes to your If coverage under this EOC is subject to the Employee doctor and have them documented in your medical Retirement Income Security Act (ERISA) claims chart, or you can put them in writing and have that procedure regulation (29 CFR 2560.503-1), then we are a included in your medical chart "named claims fiduciary" to review claims under this EOC. To learn more about advance directives, including how to obtain forms and instructions, contact the Member Services Department at a Plan Facility. You can also ERISA Notices refer to Your Guidebook for more information about This "ERISA Notices" section applies only if your advance directives. Group's health benefit plan is subject to the Employee Retirement Income Security Act (ERISA). We provide these notices to assist ERISA-covered groups in Agreement Binding on Members complying with ERISA. Coverage for Services described By electing coverage or accepting benefits under this in these notices is subject to all provisions of this EOC. EOC, all Members legally capable of contracting, and the legal representatives of all Members incapable of Newborns' and Mother's Health Protection Act contracting, agree to all provisions of this EOC. Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any

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hospital length of stay in connection with childbirth for ancestry, religion, sex, gender identity, gender the mother or newborn child to less than 48 hours expression, sexual orientation, marital status, physical or following a vaginal delivery, or less than 96 hours mental disability, source of payment, genetic following a cesarean section. However, Federal law information, citizenship, primary language, or generally does not prohibit the mother's or newborn's immigration status. attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans Notices Regarding Your Coverage and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the Our notices to you will be sent to the most recent address insurance issuer for prescribing a length of stay not in we have for the Subscriber. The Subscriber is responsible excess of 48 hours (or 96 hours). for notifying us of any change in address. Subscribers who move should call our Member Service Contact Center as soon as possible to give us their new address. Women's Health and Cancer Rights Act If a Member does not reside with the Subscriber, or If you have had or are going to have a mastectomy, you needs to have confidential information sent to an address may be entitled to certain benefits under the Women's other than the Subscriber's address, he or she should Health and Cancer Rights Act. For individuals receiving contact our Member Service Contact Center to discuss mastectomy-related benefits, coverage will be provided alternate delivery options. in a manner determined in consultation with the attending physician and the patient, for all stages of Note: When we tell your Group about changes to this reconstruction of the breast on which the mastectomy EOC or provide your Group other information that was performed, surgery and reconstruction of the other affects you, your Group is required to notify the breast to produce a symmetrical appearance, prostheses, Subscriber within 30 days (or five days if we terminate and treatment of physical complications of the your Group's Agreement) after receiving the information mastectomy, including lymphedemas. These benefits will from us. be provided subject to the same Cost Share applicable to other medical and surgical benefits provided under this plan. Overpayment Recovery We may recover any overpayment we make for Services Governing Law from anyone who receives such an overpayment or from any person or organization obligated to pay for the Except as preempted by federal law, this EOC will be Services. governed in accord with California law and any provision that is required to be in this EOC by state or federal law shall bind Members and Health Plan whether Privacy Practices or not set forth in this EOC. Kaiser Permanente will protect the privacy of Group and Members Not Our Agents your protected health information. We also require contracting providers to protect your Neither your Group nor any Member is the agent or protected health information. Your protected representative of Health Plan. health information is individually-identifiable information (oral, written, or electronic) about No Waiver your health, health care services you receive, or payment for your health care. You may Our failure to enforce any provision of this EOC will not constitute a waiver of that or any other provision, or generally see and receive copies of your impair our right thereafter to require your strict protected health information, correct or update performance of any provision. your protected health information, and ask us for an accounting of certain disclosures of your Nondiscrimination protected health information. You can request delivery of confidential communication to a We do not discriminate on the basis of age, race, location other than your usual address or by a ethnicity, color, national origin, cultural background, means of delivery other than the usual means.

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We may use or disclose your protected health Helpful Information information for treatment, health research, payment, and health care operations purposes, How to Obtain this EOC in Other such as measuring the quality of Services. We Formats are sometimes required by law to give You can request a copy of this EOC in an alternate protected health information to others, such as format (Braille, audio, electronic text file, or large print) government agencies or in judicial actions. In by calling our Member Service Contact Center. addition, protected health information is shared with your Group only with your authorization or as otherwise permitted by law. We will not Your Guidebook to Kaiser Permanente use or disclose your protected health Services (Your Guidebook) information for any other purpose without your Please refer to Your Guidebook for helpful information (or your representative's) written authorization, about your coverage, such as: except as described in our Notice of Privacy • The location of Plan Facilities in your area and the Practices (see below). Giving us authorization types of covered Services that are available from each is at your discretion. facility • How to use our Services and make appointments This is only a brief summary of some of our • Hours of operation key privacy practices. OUR NOTICE OF • Appointments and advice phone numbers PRIVACY PRACTICES, WHICH PROVIDES ADDITIONAL INFORMATION ABOUT Your Guidebook provides other important information, OUR PRIVACY PRACTICES AND YOUR such as preventive care guidelines and your Member RIGHTS REGARDING YOUR PROTECTED rights and responsibilities. Your Guidebook is subject to change and is periodically updated. You can get a copy HEALTH INFORMATION, IS AVAILABLE of Your Guidebook by visiting our website at kp.org or AND WILL BE FURNISHED TO YOU by calling our Member Service Contact Center. UPON REQUEST. To request a copy, please call our Member Service Contact Center. You can also find the notice at a Plan Facility or on Online Tools and Resources our website at kp.org. Here are some tools and resources available on our website at kp.org: • Public Policy Participation A directory of Plan Facilities and Plan Physicians • Tools you can use to email your doctor's office, view The Kaiser Foundation Health Plan, Inc., Board of test results, refill prescriptions, and schedule routine Directors establishes public policy for Health Plan. A list appointments of the Board of Directors is available on our website at • Health education resources kp.org or from our Member Service Contact Center. If you would like to provide input about Health Plan • Appointments and advice phone numbers public policy for consideration by the Board, please send written comments to: You can also access tools and resources using the KP app on your smartphone or other mobile device. Kaiser Foundation Health Plan, Inc. Office of Board and Corporate Governance Services One Kaiser Plaza, 19th Floor How to Reach Us Oakland, CA 94612 Appointments If you need to make an appointment, please call us or visit our website: Call The appointment phone number at a Plan Facility (refer to Your Guidebook or the

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facility directory on our website at kp.org for Away from home travel line phone numbers) If you have questions about your coverage when you are Website kp.org for routine (non-urgent) appointments away from home: with your personal Plan Physician or another Call 951-268-3900 Primary Care Physician 24 hours a day, seven days a week (except Not sure what kind of care you need? closed holidays) If you need advice on whether to get medical care, or Website kp.org/travel how and when to get care, we have licensed health care professionals available to assist you by phone 24 hours a Authorization for Post-Stabilization Care day, 7 days a week: To request prior authorization for Post-Stabilization Care Call The appointment or advice phone number at a as described under "Emergency Services" in the Plan Facility (refer to Your Guidebook or the "Emergency Services and Urgent Care" section: facility directory on our website at kp.org for Call 1-800-225-8883 or the notification telephone phone numbers) number on your Kaiser Permanente ID card (TTY users call 711) Member Services 24 hours a day, seven days a week If you have questions or concerns about your coverage, how to obtain Services, or the facilities where you can Help with claim forms for Emergency Services, receive care, you can reach us in the following ways: Post-Stabilization Care, Out-of-Area Urgent Call 1-800-464-4000 (English and more than 150 Care, and emergency ambulance Services languages using interpreter services) If you need a claim form to request payment or 1-800-788-0616 (Spanish) reimbursement for Services described in the "Emergency 1-800-757-7585 (Chinese dialects) Services and Urgent Care" section or under "Ambulance TTY users call 711 Services" in the "Benefits and Your Cost Share" section, 24 hours a day, seven days a week (except or if you need help completing the form, you can reach closed holidays) us by calling or by visiting our website. Visit Member Services Department at a Plan Call 1-800-464-4000 or 1-800-390-3510 (TTY Facility (refer to Your Guidebook or the users call 711) facility directory on our website at kp.org for 24 hours a day, seven days a week (except addresses) closed holidays) Write Member Services Department at a Plan Website kp.org Facility (refer to Your Guidebook or the facility directory on our website at kp.org for Submitting claims for Emergency Services, addresses) Post-Stabilization Care, Out-of-Area Urgent Website kp.org Care, and emergency ambulance Services If you need to submit a completed claim form for Estimates, bills, and statements Services described in the "Emergency Services and For the following concerns, please call us at the number Urgent Care" section or under "Ambulance Services" in below: the "Benefits and Your Cost Share" section, or if you need to submit other information that we request about • If you have questions about a bill your claim, send it to our Claims Department: • To find out how much you have paid toward your Write For Northern California Home Region Plan Deductible (if applicable) or Plan Out-of-Pocket Members: Maximum Kaiser Foundation Health Plan, Inc. • To get an estimate of Charges for Services that are Claims Department subject to the Plan Deductible (if applicable) P.O. Box 12923 Oakland, CA 94604-2923 Call 1-800-390-3507 (TTY users call 711) Monday through Friday 7 a.m. to 7 p.m. Website kp.org/memberestimates

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For Southern California Home Region pay for the care, you must submit a grievance (refer Members: to "Grievances" in the "Dispute Resolution" section) Kaiser Foundation Health Plan, Inc. • If you have coverage with another plan or with Claims Department Medicare, we will coordinate benefits with the other P.O. Box 7004 coverage (refer to "Coordination of Benefits" in the Downey, CA 90242-7004 "Exclusions, Limitations, Coordination of Benefits, and Reductions" section) Telephone access (TTY) • In some situations, you or a third party may be If you use a text telephone device (TTY, also known as responsible for reimbursing us for covered Services TDD) to communicate by phone, you can use the (refer to "Reductions" in the "Exclusions, California Relay Service by calling 711. Limitations, Coordination of Benefits, and Reductions" section) Interpreter services • You must pay the full price for noncovered Services If you need interpreter services when you call us or when you get covered Services, please let us know. Interpreter services, including sign language, are available during all business hours at no cost to you. For more information on the interpreter services we offer, please call our Member Service Contact Center.

Payment Responsibility This "Payment Responsibility" section briefly explains who is responsible for payments related to the health care coverage described in this EOC. Payment responsibility is more fully described in other sections of the EOC as described below: • Your Group is responsible for paying Premiums, except that you are responsible for paying Premiums if you have COBRA or Cal-COBRA (refer to "Premiums" in the "Premiums, Eligibility, and Enrollment" section and "COBRA" and "Cal-COBRA" under "Continuation of Group Coverage" in the "Continuation of Membership" section) • Your Group may require you to contribute to Premiums (your Group will tell you the amount and how to pay) • You are responsible for paying your Cost Share for covered Services (refer to "Your Cost Share" in the "Benefits and Your Cost Share" section) • If you receive Emergency Services, Post-Stabilization Care, or Out-of-Area Urgent Care from a Non–Plan Provider, or if you receive emergency ambulance Services, you must pay the provider and file a claim for reimbursement unless the provider agrees to bill us (refer to "Payment and Reimbursement" in the "Emergency Services and Urgent Care" section) • If you receive Services from Non–Plan Providers that we did not authorize (other than Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, or emergency ambulance Services) and you want us to

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Kaiser Foundation Health Plan, Inc. Northern California and Southern California Regions

EOC #98 - COMBINED CHIROPRACTIC AND ACUPUNCTURE SERVICES AMENDMENT OF THE KAISER FOUNDATION HEALTH PLAN, INC., EVIDENCE OF COVERAGE FOR

COVERED CALIFORNIA FOR SMALL BUSINESS

Chiropractic/Acupuncture Plan-$15 Copay/20 Visits Group ID: 799999 Group ID: 399999 Group ID: 799997 Group ID: 399997

Contract Year 2018

ASH Plans Customer Service Department Monday through Friday, 5 a.m. to 6 p.m. 1-800-678-9133 (TTY users call 711) toll free ashlink.com/ash/kp

TABLE OF CONTENTS

Health Plan Benefits and Coverage Matrix ...... 1 Introduction ...... 3 Definitions ...... 3 Participating Providers ...... 4 How to Obtain Services ...... 4 Covered Services ...... 5 Exclusions ...... 6 Customer Service ...... 7 Grievances ...... 7

Health Plan Benefits and Coverage Matrix

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

We cover the Services described below, subject to exclusions described in the "Exclusions" section, only if all of the following conditions are satisfied: • You are a Member on the date that you receive the Services • ASH Plans has determined that the Services are Medically Necessary, except as described in this Amendment • You receive the Services from Participating Providers or other licensed providers that ASH contracts to provide covered care, except as described in this Amendment

Professional Services (Plan Provider office visits) You Pay Chiropractic and acupuncture office visits (up to a combined total of 20 visits per 12-month period) ...... $15 per visit

Other You Pay X-rays and laboratory tests that are covered Chiropractic Services ...... No charge

Chiropractic supports and appliances ...... Amounts in excess of the $50 Allowance

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of- pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the "Covered Services" and "Exclusions" sections.

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Introduction Chiropractic Services: Services provided or prescribed by a chiropractor (including laboratory tests, X-rays, and chiropractic supports and appliances) for the treatment of This document amends your Kaiser Foundation your Musculoskeletal and Related Disorder. Health Plan, Inc. (Health Plan) DF/EOC to add coverage for Chiropractic Services and Acupuncture Covered Services as described in this Combined Chiropractic Emergency Acupuncture Services: Acupuncture Services provided for the treatment of a and Acupuncture Services Amendment Musculoskeletal and Related Disorder, nausea, or pain, ("Amendment"). All provisions of the DF/EOC apply to coverage described in this document except for the which manifests itself by acute symptoms of sufficient following sections: severity (including severe pain) such that a reasonable person could expect the absence of immediate • "How to Obtain Services" (except that the Acupuncture Services to result in serious jeopardy to "Completion of Services from Non–Plan Providers" your health or body functions or organs. section, or for Kaiser Permanente Senior Advantage Members, the "Termination of a Plan Provider's Emergency Chiropractic Services: Covered contract and completion of Services" section, does Chiropractic Services provided for the treatment of a apply to coverage described in this document) Musculoskeletal and Related Disorder which manifests • "Plan Facilities" itself by acute symptoms of sufficient severity (including severe pain) such that a reasonable person could expect • "Emergency Services and Urgent Care" the absence of immediate Chiropractic Services to result • "Benefits and Your Cost Share" in serious jeopardy to your health or body functions or organs. Kaiser Foundation Health Plan, Inc. contracts with American Specialty Health Plans of California, Inc. Musculoskeletal and Related Disorders: Conditions (ASH Plans) to make the ASH Plans network of with signs and symptoms related to the nervous, Participating Providers available to you. When you need muscular, and/or skeletal systems. Musculoskeletal and chiropractic care or acupuncture, you have direct access Related Disorders are conditions typically categorized as to more than 3,400 licensed chiropractors and more than structural, degenerative, or inflammatory disorders; or 2,000 licensed acupuncturists in California. You can biomechanical dysfunction of the joints of the body obtain covered Services from any Participating Provider and/or related components of the muscle or skeletal without a referral from a Plan Physician. Your Cost systems (muscles, tendons, fascia, nerves, Share is due when you receive covered Services. ligaments/capsules, discs and synovial structures) and related manifestations or conditions.

Definitions Non–Participating Provider: A provider other than a Participating Provider. In addition to the terms defined in the "Definitions" section of your Health Plan DF/EOC, the following terms, when capitalized and used in any part of this Participating Provider: An acupuncturist who is Amendment, have the following meanings: licensed to provide acupuncture services in California and who has a contract with ASH Plans to provide Medically Necessary Acupuncture Services to you, or a Acupuncture Services: The stimulation of certain points on or near the surface of the body by the insertion of chiropractor who is licensed to provide chiropractic services in California and who has a contract with ASH needles to prevent or modify the perception of pain or to normalize physiological functions (including adjunctive Plans to provide Medically Necessary Chiropractic therapies, such as acupressure, moxibustion, or breathing Services to you. A list of Participating Providers is available on the ASH Plans website at techniques, when provided during the same course of treatment and in conjunction with acupuncture) when ashlink.com/ash/kaisercamedicare for Kaiser provided by an acupuncturist for the treatment of your Permanente Senior Advantage Members, or for all other Members, or from the Musculoskeletal and Related Disorder, nausea (such as ashlink.com/ash/kp nausea related to chemotherapy, postsurgery pain, or ASH Plans Customer Service Department toll free at (TTY users call ). The list of pregnancy), or pain (such as lower back pain, shoulder 1-800-678-9133 711 pain, joint pain, or headaches). Participating Providers is subject to change at any time, without notice. If you have questions, please call the ASH Plans Customer Service Department. ASH Plans: American Specialty Health Plans of California, Inc., a California corporation.

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Treatment Plan: One of the following, depending on available from contracted providers and that are whether the Treatment Plan is for Chiropractic Services authorized in advance by ASH Plans. or Acupuncture Services: • A proposed course of treatment for your How to Obtain Services Musculoskeletal and Related Disorder, which may include laboratory tests, X-rays, chiropractic supports To obtain Services covered under this Amendment call a and appliances, and a specific number of visits for Participating Provider to schedule an initial examination. chiropractic manipulations (adjustments) and If additional Services are required after the initial adjunctive therapies that are Medically Necessary examination, verification that the Services are Medically Chiropractic Services for you Necessary may be required, as described under "Decision • A proposed course of treatment for your time frames" below. Your Participating Provider will Musculoskeletal and Related Disorder, nausea, or request any required medical necessity determinations. pain, which will include a specific number of visits An ASH Plans clinician in the same or similar specialty for acupuncture (including adjunctive therapies such as the provider of Services under review will determine as acupressure, moxibustion, or breathing techniques whether the Services are or were Medically Necessary when provided during the same course of treatment Services. and in conjunction with acupuncture) that are Medically Necessary Acupuncture Services for you Decision time frames The ASH Plans' clinician will make the authorization Urgent Acupuncture Services: Acupuncture Services decision within the time frame appropriate for your that meet all of the following requirements: condition, but no later than five business days after receiving all of the information (including additional • They are necessary to prevent serious deterioration of examination and test results) reasonably necessary to your health resulting from an unforeseen illness, make the decision, except that decisions about urgent injury, or complication of an existing condition, Services will be made no later than 72 hours after receipt including pregnancy of the information reasonably necessary to make the • They cannot be delayed until you return to the decision. If ASH Plans needs more time to make the Service Area decision because it doesn't have information reasonably necessary to make the decision, or because it has Urgent Chiropractic Services: Chiropractic Services requested consultation by a particular specialist, you and that meet all of the following requirements: your Participating Provider will be informed in writing • They are necessary to prevent serious deterioration of about the additional information, testing, or specialist your health resulting from an unforeseen illness, that is needed, and the date that ASH Plans expects to injury, or complication of an existing condition, make a decision. including pregnancy Your Participating Provider will be informed of the • They cannot be delayed until you return to the decision within 24 hours after the decision is made. If the Service Area Services are authorized, your Participating Provider will be informed of the scope of the authorized Services. If ASH Plans does not authorize all of the Services, ASH Participating Providers Plans will send you a written decision and explanation, Please read the following information so you will including the rationale for the decision and the criteria know from whom or what group of providers you used to make the decision, within two business days after may receive Services covered under this Amendment. the decision is made. The letter will also include information about your appeal rights, which are ASH Plans contracts with Participating Providers and described in the "Coverage Decisions, Appeals, and other licensed providers to provide the Services covered Complaints" section of your Health Plan DF/EOC for under this Amendment (including laboratory tests, X- Kaiser Permanente Senior Advantage Members, and rays, and chiropractic supports and appliances). You "Dispute Resolution" section of your Health Plan must receive Services covered under this Amendment DF/EOC for all other Members. Any written criteria that from a Participating Provider or another licensed ASH Plans uses to make the decision to authorize, provider with which ASH contracts to provide covered modify, delay, or deny the request for authorization will care, except for Services covered under "Emergency and be made available to you upon request. If you have urgent Services covered under this Amendment" in the questions or concerns, please contact ASH Plans or "Covered Services" section and Services that are not

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Kaiser Permanente as described under "Customer acupuncture Services under your Health Plan DF/EOC. Service" in this Amendment. You do not need a referral to get covered Services under this Amendment, but covered Services and your Cost Share may differ from those under your Health Plan Covered Services DF/EOC. If you receive acupuncture Services for which you have a referral (as described under "Getting a We cover the Services listed in this "Covered Services" Referral" in the "How to Obtain Services" section of the section, subject to exclusions described in the DF/EOC), then unless you tell us otherwise, we will "Exclusions" section, only if all of the following assume that you are using your coverage under your conditions are satisfied: Health Plan DF/EOC. • You are a Member on the date that you receive the Services If you are a Kaiser Permanente Senior Advantage • ASH Plans has determined that the Services are Member, please refer to your Health Plan DF/EOC for Medically Necessary, except for: information about the chiropractic Services that we cover in accord with Medicare guidelines, which are separate ♦ the initial examination described under "Office from the Services covered under this Amendment. Visits" in this "Covered Services" section ♦ Services covered under "Emergency and urgent Office visits Services covered under this Amendment" in this We cover up to a combined total of 20 of the following "Covered Services" section types of office visits per 12-month period at a • You receive the Services from Participating Providers $15 Copayment per visit: or other licensed providers with which ASH contracts • Initial chiropractic examination: An examination to provide covered care, except for: performed by a Participating Provider to determine ♦ Services covered under "Emergency and urgent the nature of your problem (and, if appropriate, to Services covered under this Amendment" in this prepare a Treatment Plan), and to provide Medically "Covered Services" section Necessary Chiropractic Services, which may include ♦ Services that are not available from Participating an adjustment and adjunctive therapy (such as Providers or other licensed providers with which ultrasound, hot packs, cold packs, or electrical muscle ASH contracts to provide covered care and that are stimulation). We cover an initial examination only authorized in advance by ASH Plans if you have not already received covered Chiropractic Services from a Participating Provider in the same When you receive covered Services, you must pay the 12-month period for your Musculoskeletal and Cost Share listed in this "Covered Services" section. Related Disorder If you receive Services that are not covered under this • Subsequent chiropractic office visits: Subsequent Amendment, you may be liable for the full price of those Participating Provider office visits for Chiropractic Services. Services that are determined to be Medically Necessary by an ASH Plans clinician. These Note: If Charges for Services are less than the subsequent office visits may include an adjustment, Copayment described in this "Covered Services" section, adjunctive therapy, and a re-examination to assess the you will pay the lesser amount. need to continue, extend, or change a Treatment Plan • Initial acupuncture examination: An examination The Cost Share you pay for Services covered under this performed by a Participating Provider to determine Amendment does not apply toward any Plan Deductible the nature of your problem (and, if appropriate, to or Plan Out-of-Pocket Maximum described in your prepare a Treatment Plan), and to provide Medically Health Plan DF/EOC. Necessary Acupuncture Services. We cover an initial examination only if you have not already received If you have questions about your Cost Share for specific covered Acupuncture Services from a Participating Services that you are scheduled to receive or that your Provider in the same 12-month period for your provider orders during a visit or procedure, please call Musculoskeletal and Related Disorder, nausea, or the ASH Plans Customer Service Department toll free at pain 1-800-678-9133 (TTY users call 711) weekdays from 5 a.m. to 6 p.m. • Subsequent acupuncture office visits: Subsequent Participating Provider office visits for Acupuncture Coverage of Acupuncture Services under this Services that are determined to be Medically Amendment is different from the coverage of Necessary by an ASH Plans clinician, which may

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include a re-examination to assess the need to Emergency and urgent Services covered under continue, extend, or change a Treatment Plan this Amendment Emergency and urgent chiropractic Services. We Each office visit counts toward any visit limit, cover Emergency Chiropractic Services and Urgent if applicable. Chiropractic Services provided by a Participating Provider or a Non–Participating Provider at a Laboratory tests and X-rays $15 Copayment per visit. We do not cover follow-up or We cover Medically Necessary laboratory tests and X- continuing care from a Non-Participating Provider unless rays when prescribed as part of covered chiropractic care ASH Plans has authorized the Services in advance. Also, described under "Office visits" in this "Covered we do not cover Services from a Non-Participating Services" section at no charge when a Participating Provider that ASH Plans determines are not Emergency Provider provides the Services or refers you to another Chiropractic Services or Urgent Chiropractic Services. licensed provider with which ASH contracts to provide covered Services. Emergency and urgent acupuncture Services. We cover Emergency Acupuncture Services and Urgent Chiropractic supports and appliances Acupuncture Services provided by a Participating We provide a $50 Allowance per 12-month period Provider or a Non–Participating Provider at a toward the ASH Plans fee schedule price for chiropractic $15 Copayment per visit. We do not cover follow-up or appliances listed in this paragraph when the item is continuing care from a Non–Participating Provider prescribed and provided to you by a Participating unless ASH Plans has authorized the Services in Provider as part of covered chiropractic care described advance. Also, we do not cover Services from a Non- under "Office visits" in this "Covered Services" section. Participating Provider that ASH Plans determines are not If the price of the item(s) in the ASH Plans fee schedule Emergency Acupuncture Services or Urgent exceeds $50 (the Allowance), you will pay the amount in Acupuncture Services. excess of $50 (and that payment does not apply toward the Plan Out-of-Pocket Maximum described in your How to file a claim. As soon as possible after receiving Health Plan DF/EOC). Covered chiropractic appliances Emergency Chiropractic Services or Urgent Chiropractic are limited to: elbow supports, back supports (thoracic), Services or Emergency Acupuncture Services or Urgent cervical collars, cervical pillows, heel lifts, hot or cold Acupuncture Services, you must file an ASH Plans claim packs, lumbar braces and supports, lumbar cushions, form. To request a claim form or for more information, orthotics, wrist supports, rib belts, home traction units please call ASH Plans toll free at 1-800-678-9133 (TTY (cervical or lumbar), ankle braces, knee braces, rib users call 711) or visit the ASH Plans website at supports, and wrist braces. ashlink.com. You must send the completed claim form to: Second opinions ASH Plans You may request a second opinion in regard to covered P.O. Box 509002 Services by contacting another Participating Provider. San Diego, CA 92150-9002 Your visit to another Participating Provider for a second opinion generally will count toward any visit limit, if applicable. A Participating Provider may also request a Exclusions second opinion in regard to covered Services by referring you to another Participating Provider in the same or The items and services listed in this "Exclusions" section similar specialty. When you are referred by a are excluded from coverage. These exclusions apply to Participating Provider to another Participating Provider all Services that would otherwise be covered under this for a second opinion, your visit to the other Participating Amendment regardless of whether the services are within Provider will not count toward any visit limit, the scope of a provider's license or certificate: if applicable. You have a right to a second opinion. • Acupuncture services for conditions other than If you have requested a second opinion and you have not Musculoskeletal and Related Disorders, nausea, and received it or you believe it has not been authorized, you pain can file a grievance as described under "Grievances" in this Amendment. • Acupuncture performed with reusable needles • Services provided by an acupuncturist that are not within the scope of licensure for an acupuncturist licensed in California

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• For Acupuncture Services, adjunctive therapies Customer Service unless provided during the same course of treatment and in conjunction with acupuncture If you have a question or concern regarding the Services you received from a Participating Provider or any other • Air conditioners, air purifiers, therapeutic mattresses, licensed provider with which ASH contracts to provide chiropractic appliances, durable medical equipment, covered Services, you may call the ASH Plans Customer supplies, devices, appliances, and any other item Service Department toll free at 1-800-678-9133 (TTY except those listed as covered under "Chiropractic users call 711) weekdays from 5 a.m. to 6 p.m., or write supports and appliances" in the "Covered Services" ASH Plans at: section of this Amendment • Services provided by a chiropractor that are not ASH Plans within the scope of licensure for a chiropractor Customer Service Department licensed in California P.O. Box 509002 San Diego, CA 92150-9002 • For Chiropractic Services, adjunctive therapy not associated with spinal, muscle, or joint manipulations • Services for asthma or addiction, such as nicotine Grievances addiction You can file a grievance with Kaiser Permanente • Hypnotherapy, behavior training, sleep therapy, and regarding any issue. Your grievance must explain your weight programs issue, such as the reasons why you believe a decision • Thermography was in error or why you are dissatisfied about Services you received. If you are a Kaiser Permanente Senior • Experimental or investigational Services. If coverage Advantage Member, you may submit your grievance for a Service is denied because it is experimental or orally or in writing to Kaiser Permanente as described in investigational and you want to appeal the denial, the "Coverage Decisions, Appeals, and Complaints" refer to your Health Plan DF/EOC for information section of your Health Plan DF/EOC. Otherwise, you about the appeal process may submit your grievance orally or in writing to Kaiser • CT scans, MRIs, PET scans, bone scans, nuclear Permanente as described in the "Dispute Resolution" medicine, and any other type of diagnostic imaging or section of your Health Plan DF/EOC. radiology other than X-rays covered under the "Covered Services" section of this Amendment • Ambulance and other transportation • Education programs, non-medical self-care or self- help, any self-help physical exercise training, and any related diagnostic testing • Services for pre-employment physicals or vocational rehabilitation • Drugs and medicines, including non-legend or proprietary drugs and medicines • Services you receive outside the state of California, except for Services covered under "Emergency and urgent Services covered under this Amendment" in the "Covered Services" section • Hospital services, anesthesia, manipulation under anesthesia, and related services • Dietary and nutritional supplements, such as vitamins, minerals, herbs, herbal products, injectable supplements, and similar products • Massage therapy • Maintenance care (services provided to Members whose treatment records indicate that they have reached maximum therapeutic benefit)

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